Healthcare Provider Details

I. General information

NPI: 1063338572
Provider Name (Legal Business Name): KENNEDY GARLAND JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENNEDY GRACE GARLAND

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12595 S MINUTEMAN DR
DRAPER UT
84020-9541
US

IV. Provider business mailing address

1488 HCR 3320
HUBBARD TX
76648-4791
US

V. Phone/Fax

Practice location:
  • Phone: 801-882-2618
  • Fax: 801-882-2618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number114219
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14190701-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: