Provider Demographics
NPI:1588969190
Name:GIFT, JACK ALAN (LCSW)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ALAN
Last Name:GIFT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W CONCORD DR
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2745
Mailing Address - Country:US
Mailing Address - Phone:801-814-7943
Mailing Address - Fax:
Practice Address - Street 1:313 W CONCORD DR
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-2745
Practice Address - Country:US
Practice Address - Phone:801-814-7943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT75672796005101YA0400X
UT7567279-3502104100000X
UT7567279-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7567279-3501OtherLCSW LICENSE
UT7567279-3502OtherCERTIFIED SOCIAL WORKER