Provider Demographics
NPI:1427356112
Name:EARLE, JASON STANELY
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:STANELY
Last Name:EARLE
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:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-0330
Mailing Address - Country:US
Mailing Address - Phone:801-990-4300
Mailing Address - Fax:801-967-2127
Practice Address - Street 1:3509 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2846
Practice Address - Country:US
Practice Address - Phone:801-990-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8829092-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health