Healthcare Provider Details

I. General information

NPI: 1245921956
Provider Name (Legal Business Name): JACOB KENISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 E MURRAY HOLLADAY RD STE 101
HOLLADAY UT
84117-5173
US

IV. Provider business mailing address

5111 S 4620 W
KEARNS UT
84118-5701
US

V. Phone/Fax

Practice location:
  • Phone: 801-980-2566
  • Fax:
Mailing address:
  • Phone: 917-562-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: