Provider Demographics
NPI:1720863764
Name:JACKSON, HEATHER KAYE
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:KAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1371
Mailing Address - Country:US
Mailing Address - Phone:972-658-4509
Mailing Address - Fax:
Practice Address - Street 1:1200 TOWNE CENTRE BLVD SPC 1142
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2941
Practice Address - Country:US
Practice Address - Phone:972-658-4509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF23-104260251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services