Healthcare Provider Details

I. General information

NPI: 1619832904
Provider Name (Legal Business Name): JENNY LYNN GIBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14629 S PORTER ROCKWELL BLVD STE 102
BLUFFDALE UT
84065-1968
US

IV. Provider business mailing address

14629 S PORTER ROCKWELL BLVD STE 102
BLUFFDALE UT
84065-1968
US

V. Phone/Fax

Practice location:
  • Phone: 801-410-1100
  • Fax: 844-689-3196
Mailing address:
  • Phone: 801-410-1100
  • Fax: 844-689-3196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13104031-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: