Provider Demographics
NPI:1962111294
Name:TAYLOR, JACQUELINE JENSEN
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JENSEN
Last Name:TAYLOR
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 1:1999 W NORTH TEMPLE APT B117
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3977
Mailing Address - Country:US
Mailing Address - Phone:801-864-4780
Mailing Address - Fax:
Practice Address - Street 1:1999 W NORTH TEMPLE APT B117
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3977
Practice Address - Country:US
Practice Address - Phone:801-864-4780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty