Provider Demographics
NPI:1366079097
Name:LIVE WELL COUNSELING SERVICES PLLC
Entity type:Organization
Organization Name:LIVE WELL COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:K
Authorized Official - Last Name:VICKREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-896-8133
Mailing Address - Street 1:11748 S 3600 W STE 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5922
Mailing Address - Country:US
Mailing Address - Phone:801-896-8133
Mailing Address - Fax:
Practice Address - Street 1:11748 S 3600 W STE 3
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5922
Practice Address - Country:US
Practice Address - Phone:801-896-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-24
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty