Mylisa Jacobson, CCC-SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

12638023-4102 Issued in UT

Practice address

95 White Sage Ave Ste C
Delta, UT 84624-5555

Phone

(435) 864-2551

Fax

(435) 864-3573

NPI assigned

Mar 24, 2022

Last updated

Mar 24, 2022By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1648080000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1648080000000",
    "number": "1245980176",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "95 WHITE SAGE AVE STE C",
            "city": "DELTA",
            "state": "UT",
            "postal_code": "846245555",
            "telephone_number": "435-864-2551",
            "fax_number": "435-864-3573"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "95 WHITE SAGE AVE STE C",
            "city": "DELTA",
            "state": "UT",
            "postal_code": "846245555",
            "telephone_number": "435-864-2551",
            "fax_number": "435-864-3573"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACOBSON",
        "first_name": "MYLISA",
        "credential": "CCC-SLP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-03-24",
        "last_updated": "2022-03-24",
        "certification_date": "2022-03-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "UT",
            "license": "12638023-4102",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ihc Health Services Inc (White Sage Clinic)
• Ihc Health Services Inc (Delta Community Hospital Physicians)
• Ihc Health Services, Inc (Delta Community Hospital)
• Ihc Health Services, Inc. (Intermountain Health Delta Community Hospital)
• Jamie Ipson, PTA
• Robert Preston Keel, PA-C
• Nicholas Ward Killpack, PHARMD
• Roger E Killpack, RPH
• Dustin Kunz
• Mandy Lynn Lemmon, FNP

• Speech-Language Pathologist in Delta, UT
• Providers in Delta, UT by specialty
• Speech-Language Pathologist in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.