Healthcare Provider Details

I. General information

NPI: 1639017536
Provider Name (Legal Business Name): JACOB RYAN HENINGER APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 100 S STE 5
SALT LAKE CITY UT
84102-4210
US

IV. Provider business mailing address

2925 N CHURCH ST UNIT B302
LAYTON UT
84040-6600
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12298853-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: