Healthcare Provider Details

I. General information

NPI: 1619648615
Provider Name (Legal Business Name): JACI FAULKNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 N 2000 W
CLINTON UT
84015-8638
US

IV. Provider business mailing address

PO BOX 337
LAYTON UT
84041-0337
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-4840
  • Fax: 801-525-8151
Mailing address:
  • Phone: 801-773-4840
  • Fax: 801-525-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13403293-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: