Healthcare Provider Details

I. General information

NPI: 1487294252
Provider Name (Legal Business Name): JUDICIAL SUPERVISION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5047 S GALLERIA DR
MURRAY UT
84123-4695
US

IV. Provider business mailing address

5047 S GALLERIA DR
MURRAY UT
84123-4695
US

V. Phone/Fax

Practice location:
  • Phone: 801-486-8143
  • Fax: 801-746-6090
Mailing address:
  • Phone: 801-486-8143
  • Fax: 801-746-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KARENA Z JACKSON
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 801-486-8143