Provider Demographics
NPI:1366747602
Name:RODAT, JACKIE P (LMFT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:P
Last Name:RODAT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 ALFRED WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6523
Mailing Address - Country:US
Mailing Address - Phone:801-792-3270
Mailing Address - Fax:
Practice Address - Street 1:9192 S 300 W STE 19
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2673
Practice Address - Country:US
Practice Address - Phone:801-792-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT332068-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist