Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | 12379614-2506 | UT |
NPI | 1003489022 |
---|---|
Provider Name | Jacob Hillman |
First Address | Clearfield, UT 84015-6264 |
Second Address | Layton, UT 84040-6616 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2021 |
Last Update Date | 19/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12379614-2506 | LICENSE NUMBER (01) | UT |