Provider Demographics
NPI:1841761483
Name:BURNINGHAM, JORDAN (SUDC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BURNINGHAM
Suffix:
Gender:M
Credentials:SUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 W 200 N
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2406
Mailing Address - Country:US
Mailing Address - Phone:801-330-3440
Mailing Address - Fax:
Practice Address - Street 1:4965 S 3500 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9417
Practice Address - Country:US
Practice Address - Phone:801-330-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7187189-6005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)