Healthcare Provider Details

I. General information

NPI: 1154376077
Provider Name (Legal Business Name): VICKI L JACKMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4624 HOLLADAY BLVD
SALT LAKE CITY UT
84117-5206
US

IV. Provider business mailing address

4624 HOLLADAY BLVD
SALT LAKE CITY UT
84117-5206
US

V. Phone/Fax

Practice location:
  • Phone: 801-277-2682
  • Fax: 801-277-2980
Mailing address:
  • Phone: 801-277-2682
  • Fax: 801-277-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number295232-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: