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General NPI Number Information
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NPI Number | 1063338572
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Entity Type | Individual
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Provider Name | KENNEDY GARLAND JACKSON
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Gender | Female
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Dates
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Enumeration Date | 06/29/2026
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Last Update Date | 06/29/2026
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Provider Practice Location Address
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Address Line | 12595 S MINUTEMAN DR
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City | DRAPER
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State | UT
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Zip | 84020-9541
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Country | US
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Telephone | 801-882-2618
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Fax | 801-882-2618
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Provider Business Mailing Address
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Address Line | 1488 HCR 3320
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City | HUBBARD
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State | TX
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Zip | 76648-4791
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 114219
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 14190701-3501
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License Number State | UT
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