Active NPI
Jerry Lynn Sandberg, PH.D.
- Counseling Psychologist
- Bountiful, UT
National Provider Identifier
1154400216
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counseling Psychologist
- License
- 117488-2501
- Practice address
- 1470 N Main St Ste B
Bountiful, UT 84010-5996 - Phone
- (801) 299-9026
- Fax
- (801) 299-9026
- NPI assigned
- Nov 2, 2006
- Last updated
- Jun 15, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counseling Psychologist | 103TC1900X | 117488-2501 | UT | Primary |
Addresses
Primary practice location
1470 N Main St Ste B
Bountiful, UT 84010-5996
Mailing address
1470 N Main St Ste B
Bountiful, UT 84010-5996
Phone (801) 299-9026
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 117488-2501 | UT | MD | Counseling Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Martha a. Keil LCSW PC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1162425600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1339718400000",
"number": "1154400216",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1470 N MAIN ST STE B",
"city": "BOUNTIFUL",
"state": "UT",
"postal_code": "840105996",
"telephone_number": "801-299-9026",
"fax_number": "801-299-9026"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1470 N MAIN ST STE B",
"city": "BOUNTIFUL",
"state": "UT",
"postal_code": "840105996",
"telephone_number": "801-299-9026",
"fax_number": "801-299-9026"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SANDBERG",
"first_name": "JERRY",
"middle_name": "LYNN",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-11-02",
"last_updated": "2012-06-15",
"status": "A"
},
"taxonomies": [
{
"code": "103TC1900X",
"taxonomy_group": "",
"desc": "Psychologist, Counseling",
"state": "UT",
"license": "117488-2501",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bountiful, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.