Provider Demographics
NPI:1447481205
Name:JACKSON, JEFFREY BROWN (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BROWN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 N 1230 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-6512
Mailing Address - Country:US
Mailing Address - Phone:801-815-8105
Mailing Address - Fax:
Practice Address - Street 1:450 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2860
Practice Address - Country:US
Practice Address - Phone:801-815-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5731350-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist