Provider Demographics
NPI:1720775448
Name:JOHNSON, DAXTON MARK
Entity Type:Individual
Prefix:
First Name:DAXTON
Middle Name:MARK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 E AMERICAN WAY UNIT 9
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-6316
Mailing Address - Country:US
Mailing Address - Phone:801-864-0600
Mailing Address - Fax:
Practice Address - Street 1:5296 S 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-4767
Practice Address - Country:US
Practice Address - Phone:801-921-7854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health