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General NPI Number Information
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NPI Number | 1447481205
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Entity Type | Individual
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Provider Name | JEFFREY BROWN JACKSON PH.D., LMFT
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Gender | Male
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Dates
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Enumeration Date | 07/28/2009
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Last Update Date | 07/28/2009
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Provider Practice Location Address
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Address Line | 450 N UNIVERSITY AVE SUITE 204
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City | PROVO
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State | UT
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Zip | 84601-2860
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Country | US
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Telephone | 801-815-8105
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Fax |
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Provider Business Mailing Address
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Address Line | 1372 N 1230 W
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City | OREM
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State | UT
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Zip | 84057-6512
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Country | US
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Telephone | 801-815-8105
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 5731350-3902
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License Number State | UT
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