Healthcare Provider Details

I. General information

NPI: 1659708683
Provider Name (Legal Business Name): CODY NORTHUP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
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 Code1041C0700X
TaxonomyClinical Social Worker
License Number8821816-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: