Provider Demographics
NPI:1073944765
Name:JACKSON, EMILEE
Entity Type:Individual
Prefix:
First Name:EMILEE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 S 3900 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-8707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4640 S 3900 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-8707
Practice Address - Country:US
Practice Address - Phone:801-710-3304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker