Healthcare Provider Details

I. General information

NPI: 1801541511
Provider Name (Legal Business Name): JACOB SHANE SMITH ACMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 E CAMPUS DR STE 101
EAGLE MOUNTAIN UT
84005-5451
US

IV. Provider business mailing address

2418 E HITCHING POST DR
EAGLE MOUNTAIN UT
84005-2004
US

V. Phone/Fax

Practice location:
  • Phone: 801-789-7780
  • Fax:
Mailing address:
  • Phone: 801-608-9301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8519497-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8519497-6101
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: