Healthcare Provider Details

I. General information

NPI: 1447481205
Provider Name (Legal Business Name): JEFFREY BROWN JACKSON PH.D., LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 07/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N UNIVERSITY AVE SUITE 204
PROVO UT
84601-2860
US

IV. Provider business mailing address

1372 N 1230 W
OREM UT
84057-6512
US

V. Phone/Fax

Practice location:
  • Phone: 801-815-8105
  • Fax:
Mailing address:
  • Phone: 801-815-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number5731350-3902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: