Healthcare Provider Details

I. General information

NPI: 1619832904
Provider Name (Legal Business Name): JENNY LYNN GIBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5075 S WESLEY RD
MURRAY UT
84117-6623
US

IV. Provider business mailing address

5075 S WESLEY RD
MURRAY UT
84117-6623
US

V. Phone/Fax

Practice location:
  • Phone: 940-808-9938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13104031-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: