Provider Demographics
NPI:1154400216
Name:SANDBERG, JERRY LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 N MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5996
Mailing Address - Country:US
Mailing Address - Phone:801-299-9026
Mailing Address - Fax:801-299-9026
Practice Address - Street 1:1470 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5996
Practice Address - Country:US
Practice Address - Phone:801-299-9026
Practice Address - Fax:801-299-9026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117488-2501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000074002Medicare ID - Type UnspecifiedMEDICARE NUMER
UTR34562Medicare UPIN