Basic Information
| Provider Information | |||||||||
| NPI: | 1215457684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUNSAKER | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
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| Credential: | MMFT, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N 400 E STE 104 | ||||||||
| Address2: | |||||||||
| City: | NORTH LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843417595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556061 | ||||||||
| FaxNumber: | 4357556091 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 N 400 E STE 104 | ||||||||
| Address2: | |||||||||
| City: | NORTH LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843417595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556061 | ||||||||
| FaxNumber: | 4357556091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 106H00000X | 9424876-3902 | UT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9424876-3902 | 01 | UT | STATE OF UTAH DEPARTMENT OF COMMERCE, DOPL | OTHER |