| Ejay Jack, LCSW | |
|
389 S 900 E, Salt Lake City, UT 84102-2310 | |
| (385) 282-2500 | |
| (385) 282-2501 |
| Full Name | Ejay Jack |
|---|---|
| Gender | Male |
| Speciality | Social Worker - Clinical |
| Location | 389 S 900 E, Salt Lake City, Utah |
| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1306500590 | NPI | - | NPPES |
| 12490452-3501 | Other | UT | STATE OF UTAH DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING, LCSW LICENSE |
| 24475 | Other | MN | STATE OF MINNESOTA BOARD OF SOCIAL WORK, LICSW LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 24475 (Minnesota) | Secondary |
| 1041C0700X | Social Worker - Clinical | 12490452-3501 (Utah) | Primary |
| Entity Name | Ihc Health Services Inc |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1942325154 PECOS PAC ID: 1850209420 Enrollment ID: O20080610000303 |
| Mailing Address | Practice Location Address |
|---|---|
| Ejay Jack, LCSW 389 S 900 E, Salt Lake City, UT 84102-2310 Ph: (385) 282-2500 | Ejay Jack, LCSW 389 S 900 E, Salt Lake City, UT 84102-2310 Ph: (385) 282-2500 |
Mr. Glen Ray Lambert, LCSW Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: 1361 Rebecca Cir, Salt Lake City, UT 84117 Phone: 801-272-7742 Fax: 801-322-2831 | |
Mr. Mark Lynn Duke, LCSW Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: 132 South State, Suite 200, Salt Lake City, UT 84111 Phone: 801-240-3556 | |
Kristine Louise Nelson, LCSW Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: Va Slc, 500 Foothill Blvd, Salt Lake City, UT 84148 Phone: 801-582-1565 | |
Dr. Joel L Millard, DSW, LCSW Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: 150 E 700 S, Salt Lake City, UT 84111 Phone: 801-364-8080 Fax: 801-364-8098 | |
Matthew Kael Nisson, Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: 5965 S 900 E, Salt Lake City, UT 84121 Phone: 801-263-7100 | |
Michael Keith Slade, MSW Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: 2872 S Highland Dr, Salt Lake City, UT 84106 Phone: 801-485-8051 | |
Laura Marie Baumgart, LCSW Clinical Social Worker Medicare: Not Enrolled in Medicare Practice Location: 1390 S 1100 E Ste 204, Salt Lake City, UT 84105 Phone: 734-306-1279 |