Provider Demographics
NPI:1669646626
Name:JACKETTA, CHRISTIN LEIGH
Entity Type:Individual
Prefix:MISS
First Name:CHRISTIN
Middle Name:LEIGH
Last Name:JACKETTA
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 1:1338 MOSSY SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4731
Mailing Address - Country:US
Mailing Address - Phone:801-915-3892
Mailing Address - Fax:
Practice Address - Street 1:1338 MOSSY SPRINGS LN
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4731
Practice Address - Country:US
Practice Address - Phone:801-915-3892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT498843735011041C0700X
1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool