Provider Demographics
NPI:1831688233
Name:BLACK, JED (INTERN)
Entity type:Individual
Prefix:
First Name:JED
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 N 2000 W STE J
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8563
Mailing Address - Country:US
Mailing Address - Phone:801-855-7999
Mailing Address - Fax:801-855-7999
Practice Address - Street 1:1407 N 2000 W STE J
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8563
Practice Address - Country:US
Practice Address - Phone:801-855-7999
Practice Address - Fax:801-855-7999
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health