Provider Demographics
NPI:1831520535
Name:COTTLE, JEREMY (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:COTTLE
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 S 1440 E
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-3523
Mailing Address - Country:US
Mailing Address - Phone:801-836-4605
Mailing Address - Fax:
Practice Address - Street 1:1350 E 750 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4345
Practice Address - Country:US
Practice Address - Phone:801-836-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7765390-35011041C0700X
TX325271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical