Provider Demographics
NPI:1912722935
Name:ANDERSON, JEREMY DALLAS
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DALLAS
Last Name:ANDERSON
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 1:210 N 3600 W
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7114
Mailing Address - Country:US
Mailing Address - Phone:801-628-0113
Mailing Address - Fax:
Practice Address - Street 1:780 S 2000 W STE E302
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9611
Practice Address - Country:US
Practice Address - Phone:801-896-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14191462-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist