Provider Demographics
NPI:1174172290
Name:SEGO, JAISHA REBECCA
Entity type:Individual
Prefix:
First Name:JAISHA
Middle Name:REBECCA
Last Name:SEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 N FREEDOM BLVD APT 138
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1527
Mailing Address - Country:US
Mailing Address - Phone:385-404-9334
Mailing Address - Fax:
Practice Address - Street 1:1140 W. 1130 S.
Practice Address - Street 2:BUILDING B
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-2888
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician