Healthcare Provider Details

I. General information

NPI: 1124919733
Provider Name (Legal Business Name): JORDAN ELI KWAMANAKWEENDA PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 07/11/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5965 S 900 E STE 100
MURRAY UT
84121-1850
US

IV. Provider business mailing address

1700 W 1750 S 306
SALT LAKE CITY UT
84104-8410
US

V. Phone/Fax

Practice location:
  • Phone: 888-762-7938
  • Fax:
Mailing address:
  • Phone: 717-283-6384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number13571777-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: