Provider Demographics
NPI:1821616368
Name:JACKSON, KARENA Z (LPPP)
Entity Type:Individual
Prefix:
First Name:KARENA
Middle Name:Z
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5047 S GALLERIA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4695
Mailing Address - Country:US
Mailing Address - Phone:801-486-8143
Mailing Address - Fax:801-746-6090
Practice Address - Street 1:5047 S GALLERIA DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-4695
Practice Address - Country:US
Practice Address - Phone:801-486-8143
Practice Address - Fax:801-746-6090
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator