Provider Demographics
NPI:1316673817
Name:THACKERAY, KAITLYN JO (CSW, CPH)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:JO
Last Name:THACKERAY
Suffix:
Gender:F
Credentials:CSW, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4073 S ACORD WAY
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-4009
Mailing Address - Country:US
Mailing Address - Phone:385-449-8536
Mailing Address - Fax:
Practice Address - Street 1:11260 S RIVER HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5119
Practice Address - Country:US
Practice Address - Phone:801-298-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12923253-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker