Provider Demographics
NPI:1659016061
Name:WHITNACK-DAVIDSON, JESSIE ANNA JEAN
Entity Type:Individual
Prefix:
First Name:JESSIE ANNA
Middle Name:JEAN
Last Name:WHITNACK-DAVIDSON
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 1:476 HERITAGE PARK BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5679
Mailing Address - Country:US
Mailing Address - Phone:801-425-0227
Mailing Address - Fax:
Practice Address - Street 1:476 HERITAGE PARK BLVD STE 220
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5679
Practice Address - Country:US
Practice Address - Phone:801-425-0227
Practice Address - Fax:801-627-8817
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical