Healthcare Provider Details

I. General information

NPI: 1730002866
Provider Name (Legal Business Name): JORDAN ANDREW BOYACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 E 14075 S STE 110
DRAPER UT
84020-5725
US

IV. Provider business mailing address

4137 S 900 E APT A
MILLCREEK UT
84124-1284
US

V. Phone/Fax

Practice location:
  • Phone: 801-899-0732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14293543-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: