Healthcare Provider Details

I. General information

NPI: 1265244792
Provider Name (Legal Business Name): ABIGAIL BRIENN JACKETTA CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 S MARIO CAPECCHI DR
SALT LAKE CITY UT
84132-0005
US

IV. Provider business mailing address

14181 S HOLLOW VISTA CV
HERRIMAN UT
84096-3957
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2352
  • Fax:
Mailing address:
  • Phone: 801-673-8383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number187674
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: