Basic Information
| Provider Information | |||||||||
| NPI: | 1700401767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTEBAN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | CLARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 E OSBORNE ESTATE CIR | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840208259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016697908 | ||||||||
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| Practice Location | |||||||||
| Address1: | 440 S 500 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841022705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013598862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 11788173-3506 | UT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.