Healthcare Provider Details

I. General information

NPI: 1841433869
Provider Name (Legal Business Name): DAWN FLEMING JACKSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S 600 E SUITE 4A AMBASSADOR PLAZA
SALT LAKE CITY UT
84102-1999
US

IV. Provider business mailing address

150 S 600 E SUITE 4A AMBASSADOR PLAZA
SALT LAKE CITY UT
84102-1999
US

V. Phone/Fax

Practice location:
  • Phone: 801-364-3222
  • Fax: 801-364-3336
Mailing address:
  • Phone: 801-364-3222
  • Fax: 801-364-3336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number5081773-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: