Provider Demographics
NPI:1093227209
Name:JACKMAN, PAUL (MA, AMFT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:M
Credentials:MA, AMFT
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:JACKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, AMFT
Mailing Address - Street 1:1500 E 2700 S
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-4000
Mailing Address - Country:US
Mailing Address - Phone:435-669-1948
Mailing Address - Fax:
Practice Address - Street 1:2994 S GOULD WASH RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737
Practice Address - Country:US
Practice Address - Phone:435-635-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10100228-3904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health