Provider Demographics
NPI:1801113360
Name:RUSH, JEFFREY (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:RUSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9818
Mailing Address - Country:US
Mailing Address - Phone:435-757-3562
Mailing Address - Fax:
Practice Address - Street 1:351 MEADOW LN
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9818
Practice Address - Country:US
Practice Address - Phone:435-757-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5180207-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical