Provider Demographics
NPI:1962974295
Name:WEBB, JACK G III (CMHC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:WEBB
Suffix:III
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E MAIN ST STE L4
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2490
Mailing Address - Country:US
Mailing Address - Phone:801-980-3676
Mailing Address - Fax:
Practice Address - Street 1:2183 W MAIN ST STE A209
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-6760
Practice Address - Country:US
Practice Address - Phone:385-352-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11205735-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program