Basic Information
Provider Information
NPI: 1003002544
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HYDE
FirstName: JACQUELINE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10151 MAJESTIC CANYON RD
Address2:  
City: SANDY
State: UT
PostalCode: 840924521
CountryCode: US
TelephoneNumber: 8018095050
FaxNumber:  
Practice Location
Address1: 10151 MAJESTIC CANYON RD
Address2:  
City: SANDY
State: UT
PostalCode: 840924521
CountryCode: US
TelephoneNumber: 8018095050
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/19/2007
LastUpdateDate: 06/30/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X7324191-6009UTY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


Home