Provider Demographics
NPI:1891422077
Name:GIBBY, JORDAN GRANT (LMFT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:GRANT
Last Name:GIBBY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W BROADWAY STE 333 #455777
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101
Mailing Address - Country:US
Mailing Address - Phone:801-438-4059
Mailing Address - Fax:
Practice Address - Street 1:1452 E 820 N UPPR LEVEL
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5481
Practice Address - Country:US
Practice Address - Phone:801-438-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-06
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9045156-3904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health