Provider Demographics
NPI:1588399281
Name:FLETCHER, JACOB (LCMHC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 N EVANS RANCH DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5090
Mailing Address - Country:US
Mailing Address - Phone:714-875-3593
Mailing Address - Fax:
Practice Address - Street 1:3375 W MAYFLOWER WAY
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3134
Practice Address - Country:US
Practice Address - Phone:801-331-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT118110476004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health