Healthcare Provider Details

I. General information

NPI: 1245546589
Provider Name (Legal Business Name): FLORENCE W JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 05/25/2021
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 S WASATCH BLVD STE 330B
SALT LAKE CITY UT
84124-4794
US

IV. Provider business mailing address

4505 S WASATCH BLVD STE 330B
SALT LAKE CITY UT
84124-4794
US

V. Phone/Fax

Practice location:
  • Phone: 801-455-7985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6224346-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: