Healthcare Provider Details

I. General information

NPI: 1467149914
Provider Name (Legal Business Name): JAMIELYN EKIKO GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 E 200 N
LOGAN UT
84321-4034
US

IV. Provider business mailing address

90 E 200 N
LOGAN UT
84321-4034
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-0750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: