Provider Demographics
NPI:1316716921
Name:GIANCHETTA, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GIANCHETTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 W 750 S STE A
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7221
Mailing Address - Country:US
Mailing Address - Phone:801-935-8449
Mailing Address - Fax:
Practice Address - Street 1:512 W 750 S STE A
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-7221
Practice Address - Country:US
Practice Address - Phone:801-935-8449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF23-109242171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty