Basic Information
Provider Information | |||||||||
NPI: | 1669775854 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CRANE | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1140 W 500 S STE 9 | ||||||||
Address2: |   | ||||||||
City: | VERNAL | ||||||||
State: | UT | ||||||||
PostalCode: | 840782912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357896300 | ||||||||
FaxNumber: | 3572563254 | ||||||||
Practice Location | |||||||||
Address1: | 1140 W 500 S STE 9 | ||||||||
Address2: |   | ||||||||
City: | VERNAL | ||||||||
State: | UT | ||||||||
PostalCode: | 840782912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357896300 | ||||||||
FaxNumber: | 4357256325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2010 | ||||||||
LastUpdateDate: | 02/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7717942-3502 | UT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.