Provider Demographics
NPI:1982097127
Name:BUSTAMANTE, JAMIE LEIGH (PHD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEIGH
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E 300 S STE 6
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2332
Mailing Address - Country:US
Mailing Address - Phone:018-618-0852
Mailing Address - Fax:
Practice Address - Street 1:409 W 400 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1135
Practice Address - Country:US
Practice Address - Phone:801-364-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4602103T00000X
UT102501922501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1982097127Medicaid
AZ20504Medicaid