Provider Demographics
NPI:1912418898
Name:JACQUEZ, NATHAN (CMHC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:JACQUEZ
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E 200 S STE 110-D
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2157
Mailing Address - Country:US
Mailing Address - Phone:801-941-0364
Mailing Address - Fax:
Practice Address - Street 1:455 E 200 S STE 110-D
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2157
Practice Address - Country:US
Practice Address - Phone:801-941-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11139845-6004101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator