Provider Demographics
NPI:1306500590
Name:JACK, EJAY (LCSW)
Entity type:Individual
Prefix:
First Name:EJAY
Middle Name:
Last Name:JACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2310
Mailing Address - Country:US
Mailing Address - Phone:385-282-2500
Mailing Address - Fax:385-282-2501
Practice Address - Street 1:389 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:385-282-2500
Practice Address - Fax:385-282-2501
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN244751041C0700X
UT12490452-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12490452-3501OtherSTATE OF UTAH DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING, LCSW LICENSE
MN24475OtherSTATE OF MINNESOTA BOARD OF SOCIAL WORK, LICSW LICENSE