Provider Demographics
NPI:1790482495
Name:EMPOWERED MIND
Entity Type:Organization
Organization Name:EMPOWERED MIND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-896-3260
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:801-963-2608
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:801-896-3260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8914131-3501OtherLICENSED CLINICAL SOCIAL WORKER