Healthcare Provider Details

I. General information

NPI: 1962912501
Provider Name (Legal Business Name): JACOB GRANT BROWN CMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST
SALT LAKE CITY UT
84101-3176
US

IV. Provider business mailing address

3725 W 4100 S STE 201
WEST VALLEY CITY UT
84120-6490
US

V. Phone/Fax

Practice location:
  • Phone: 888-949-4864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10540388-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-16935
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: