Healthcare Provider Details

I. General information

NPI: 1053885285
Provider Name (Legal Business Name): REBECCA WHITAKER JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 E COTTONWOOD PKWY STE 500
SALT LAKE CITY UT
84121-7060
US

IV. Provider business mailing address

972 N 370 E
AMERICAN FORK UT
84003-1347
US

V. Phone/Fax

Practice location:
  • Phone: 801-448-6195
  • Fax:
Mailing address:
  • Phone: 385-482-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number19-75058
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: