Healthcare Provider Details

I. General information

NPI: 1649973850
Provider Name (Legal Business Name): JOHN LAWRENCE JACKSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 S 700 E APT C
SALT LAKE CITY UT
84106-1682
US

IV. Provider business mailing address

3056 S 700 E APT C
SALT LAKE CITY UT
84106-1682
US

V. Phone/Fax

Practice location:
  • Phone: 706-936-6422
  • Fax:
Mailing address:
  • Phone: 706-936-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number12900024-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: