Provider Demographics
NPI:1346724697
Name:CALLAHAN, JAZMINE ALEXII
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:ALEXII
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1229
Mailing Address - Country:US
Mailing Address - Phone:853-220-9498
Mailing Address - Fax:
Practice Address - Street 1:3350 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1229
Practice Address - Country:US
Practice Address - Phone:385-220-9498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-22
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
172V00000X
UT12880088-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTGQS150141699OtherREGENCE