Provider Demographics
NPI:1053889501
Name:VICKREY, JACOB K (LCSW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:K
Last Name:VICKREY
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 1:14664 S WARD HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1256
Mailing Address - Country:US
Mailing Address - Phone:760-792-3671
Mailing Address - Fax:
Practice Address - Street 1:11748 S 3600 W STE 3
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5922
Practice Address - Country:US
Practice Address - Phone:801-896-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9742056-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical