Provider Demographics
NPI:1982992798
Name:ANDERSEN, JACLYN (CSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 W 1000 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-2239
Mailing Address - Country:US
Mailing Address - Phone:435-757-0917
Mailing Address - Fax:
Practice Address - Street 1:380 W 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-6813
Practice Address - Country:US
Practice Address - Phone:435-752-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT77503153502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker