Basic Information
| Provider Information | |||||||||
| NPI: | 1427356112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EARLE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | STANELY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 330 | ||||||||
| Address2: | |||||||||
| City: | MAGNA | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840440330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
| FaxNumber: | 8019672127 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 W 4700 S | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2011 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 8829092-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.