Healthcare Provider Details

I. General information

NPI: 1255288122
Provider Name (Legal Business Name): JAYDALE LOGAN HANSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

986 W 9000 S STE 200
WEST JORDAN UT
84088-5729
US

IV. Provider business mailing address

986 W 9000 S STE 200
WEST JORDAN UT
84088-5729
US

V. Phone/Fax

Practice location:
  • Phone: 385-354-5250
  • Fax:
Mailing address:
  • Phone: 385-354-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1387936
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: