Provider Demographics
NPI:1902424252
Name:JARVIS, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:JARVIS
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 1:40 W CACHE VALLEY BLVD STE 7A
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-8475
Mailing Address - Country:US
Mailing Address - Phone:435-538-2152
Mailing Address - Fax:
Practice Address - Street 1:40 W CACHE VALLEY BLVD STE 7A
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-8475
Practice Address - Country:US
Practice Address - Phone:435-538-2152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11881326-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD
UT8760003008007Medicaid
UT000055266OtherMEDICARE PIN