Healthcare Provider Details

I. General information

NPI: 1255069902
Provider Name (Legal Business Name): JANA DICKSON TIBBITTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 W BAXTER DR
SOUTH JORDAN UT
84095-8506
US

IV. Provider business mailing address

873 W BAXTER DR
SOUTH JORDAN UT
84095-8506
US

V. Phone/Fax

Practice location:
  • Phone: 801-446-3515
  • Fax: 801-601-1578
Mailing address:
  • Phone: 801-446-3515
  • Fax: 801-601-1578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: