Healthcare Provider Details

I. General information

NPI: 1396689998
Provider Name (Legal Business Name): NUTRIX UTAH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 W WIDE HOLLOW DR
HERRIMAN UT
84096-3550
US

IV. Provider business mailing address

6621 W WIDE HOLLOW DR
HERRIMAN UT
84096-3550
US

V. Phone/Fax

Practice location:
  • Phone: 801-425-2831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSE GOODMAN
Title or Position: PRESIDENT
Credential: PMHNP
Phone: 801-425-2831