Healthcare Provider Details

I. General information

NPI: 1700554110
Provider Name (Legal Business Name): CHRYSTAL BRACKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 W SOUTH JORDAN PKWY STE 202
SOUTH JORDAN UT
84095-4712
US

IV. Provider business mailing address

1258 W SOUTH JORDAN PKWY STE 202
SOUTH JORDAN UT
84095-4712
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-1155
  • Fax: 801-255-0281
Mailing address:
  • Phone: 801-255-1155
  • Fax: 801-255-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13410071-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: