Healthcare Provider Details

I. General information

NPI: 1891422077
Provider Name (Legal Business Name): JORDAN GRANT GIBBY LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 E 820 N UPPR LEVEL
OREM UT
84097-5481
US

IV. Provider business mailing address

50 W BROADWAY STE 333 #455777
SALT LAKE CITY UT
84101
US

V. Phone/Fax

Practice location:
  • Phone: 801-438-4059
  • Fax:
Mailing address:
  • Phone: 801-438-4059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9045156-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: