Provider Demographics
NPI:1518559814
Name:HANSEN, SAMUEL JACOB
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACOB
Last Name:HANSEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5676 S MAGIC DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8220
Mailing Address - Country:US
Mailing Address - Phone:801-867-5170
Mailing Address - Fax:
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-1757
Practice Address - Country:US
Practice Address - Phone:801-639-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7477111-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical