Healthcare Provider Details

I. General information

NPI: 1588969190
Provider Name (Legal Business Name): JACK ALAN GIFT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W CONCORD DR
HARRISVILLE UT
84404-2745
US

IV. Provider business mailing address

313 W CONCORD DR
HARRISVILLE UT
84404-2745
US

V. Phone/Fax

Practice location:
  • Phone: 801-814-7943
  • Fax:
Mailing address:
  • Phone: 801-814-7943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number75672796005
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7567279-3502
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7567279-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: