Individual
EJAY JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
389 S 900 E, SALT LAKE CITY, UT 84102-2310
(385) 282-2500
(385) 282-2501
Mailing address
389 S 900 E, SALT LAKE CITY, UT 84102-2310
(385) 282-2500
(385) 282-2501
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
12490452-3501
UT
1041C0700X
Clinical Social Worker
24475
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12490452-3501
STATE OF UTAH DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING, LCSW LICENSE
UT
01
—
24475
STATE OF MINNESOTA BOARD OF SOCIAL WORK, LICSW LICENSE
MN
Enumeration date
10/25/2021
Last updated
10/25/2021
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