1417038951 NPI number — PSYCHOLOGICAL ASSESSMENT & TREATMENT SPECIALISTS, INC

Table of content: AMY CF JACOBSON APRN (NPI 1396226551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417038951 NPI number — PSYCHOLOGICAL ASSESSMENT & TREATMENT SPECIALISTS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGICAL ASSESSMENT & TREATMENT SPECIALISTS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417038951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
814 BAMBERGER DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
AMERICAN FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-2165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-772-0202
Provider Business Mailing Address Fax Number:
801-772-0139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
814 BAMBERGER DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
AMERICAN FORK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84003-2165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-772-0202
Provider Business Practice Location Address Fax Number:
801-772-0139
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GENTRY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT/EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
801-772-0202

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  276564-2501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 529217859009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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