Healthcare Provider Details

I. General information

NPI: 1679381560
Provider Name (Legal Business Name): JACOB FIKE ACMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 08/02/2025
Certification Date: 08/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6975 S UNION PARK CTR # 621
COTTONWOOD HEIGHTS UT
84047-6048
US

IV. Provider business mailing address

971 W DEBONAIR DR
SALT LAKE CITY UT
84116-2120
US

V. Phone/Fax

Practice location:
  • Phone: 801-477-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14197652-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: