Healthcare Provider Details

I. General information

NPI: 1932029105
Provider Name (Legal Business Name): JACLYN L STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 E 12200 S
DRAPER UT
84020-9884
US

IV. Provider business mailing address

10702 S 865 E
SANDY UT
84094-4908
US

V. Phone/Fax

Practice location:
  • Phone: 801-776-2220
  • Fax:
Mailing address:
  • Phone: 801-867-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number9278820-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: