Healthcare Provider Details

I. General information

NPI: 1134762594
Provider Name (Legal Business Name): THOMAS JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14717 S MINUTEMAN DR
DRAPER UT
84020-9549
US

IV. Provider business mailing address

467 E 100 S
MANTI UT
84642-1416
US

V. Phone/Fax

Practice location:
  • Phone: 435-835-8293
  • Fax:
Mailing address:
  • Phone: 435-835-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9100065-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9100065-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: