Healthcare Provider Details

I. General information

NPI: 1972244655
Provider Name (Legal Business Name): JACKSON ROYAL RICHARDS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W 3300 S
SOUTH SALT LAKE UT
84119-3325
US

IV. Provider business mailing address

10954 S COASTAL DUNE DR
SOUTH JORDAN UT
84009-4706
US

V. Phone/Fax

Practice location:
  • Phone: 801-583-2500
  • Fax:
Mailing address:
  • Phone: 319-356-1373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR-12525
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: