Healthcare Provider Details

I. General information

NPI: 1275514994
Provider Name (Legal Business Name): KENNETH CONRAD JACKSON II PHARM.D., R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 CHIPETA WAY SUITE 220
SALT LAKE CITY UT
84108-1236
US

IV. Provider business mailing address

2731 HARTFORD ST
SALT LAKE CITY UT
84106-3652
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7246
  • Fax: 801-581-6243
Mailing address:
  • Phone: 801-487-2169
  • Fax: 801-581-6243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number363584-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: