Healthcare Provider Details

I. General information

NPI: 1912983446
Provider Name (Legal Business Name): JAMAL AHMED BARAKAT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 S HIGHLAND DR
SALT LAKE CITY UT
84124-3543
US

IV. Provider business mailing address

2472 S 300 E
SALT LAKE CITY UT
84115-2895
US

V. Phone/Fax

Practice location:
  • Phone: 888-949-4864
  • Fax: 801-415-7533
Mailing address:
  • Phone: 801-415-7429
  • Fax: 801-415-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number325010-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: