Provider Demographics
NPI:1750020350
Name:JACK, KRISTY ANN (CCC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:ANN
Last Name:JACK
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4332 W GOLF CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-9780
Mailing Address - Country:US
Mailing Address - Phone:801-243-8094
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9438741-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist