Healthcare Provider Details

I. General information

NPI: 1407664402
Provider Name (Legal Business Name): AMELIA JACKSON M.S., SLP-CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 E 12300 S UNIT 933
DRAPER UT
84020-7976
US

IV. Provider business mailing address

138 E 12300 S UNIT 933
DRAPER UT
84020-7976
US

V. Phone/Fax

Practice location:
  • Phone: 385-352-3983
  • Fax:
Mailing address:
  • Phone: 385-352-3983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12333349-4102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: