Ejay Jack, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

12490452-3501 Issued in UT

Practice address

389 S 900 E
Salt Lake City, UT 84102-2310

Phone

(385) 282-2500

Fax

(385) 282-2501

NPI assigned

Oct 25, 2021

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 2

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Ihc Health Services Inc

  • Multi-Specialty Clinic/Center
  • Sandy, UT
  • NPI 1942325154
  Medicare reassignment NPD
• Ihc Health Services Inc

  • Internal Medicine Physician
  • Salt Lake City, UT
  • NPI 1629107305
  NPD
• Ihc Health Services, Inc.

  • Psychiatry Physician
  • St George, UT
  • NPI 1023843844
  NPD

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

{
    "created_epoch": "1635120000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1635120000000",
    "number": "1306500590",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "389 S 900 E",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841022310",
            "telephone_number": "385-282-2500",
            "fax_number": "385-282-2501"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "389 S 900 E",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841022310",
            "telephone_number": "385-282-2500",
            "fax_number": "385-282-2501"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACK",
        "first_name": "EJAY",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-10-25",
        "last_updated": "2021-10-25",
        "certification_date": "2021-10-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "24475",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "UT",
            "license": "12490452-3501",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF UTAH DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING, LCSW LICENSE",
            "identifier": "12490452-3501",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF MINNESOTA BOARD OF SOCIAL WORK, LICSW LICENSE",
            "identifier": "24475",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://intermountainhealthcare.org/",
            "affiliation": "N",
            "endpointDescription": "Intermountain Healthcare Salt Lake Clinic",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "SALT LAKE CITY",
            "address_1": "389 S 900 E",
            "city": "Salt Lake City",
            "state": "UT",
            "country_code": "US",
            "postal_code": "841022310",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Nour Jaatoul, CSW
• Dana Othman Jaber
• Joshua Vijayanand Jabez, M.D.
• Ismahan Jaburi II
• Jared Alton Jaccard, LMT
• Heather Jack
• Abigail Brienn Jacketta, CST
• Danielle Marie Jacketta
• Julie Jackman
• Matthew Adrian Jackman

• Clinical Social Worker in Salt Lake City, UT
• Providers in Salt Lake City, UT by specialty
• Clinical Social Worker in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.