Healthcare Provider Details

I. General information

NPI: 1881375962
Provider Name (Legal Business Name): ANGELA T JACOBS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 10/09/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 E 12225 S STE 204
DRAPER UT
84020-8385
US

IV. Provider business mailing address

668 E 12225 S STE 204
DRAPER UT
84020-8385
US

V. Phone/Fax

Practice location:
  • Phone: 801-899-6220
  • Fax:
Mailing address:
  • Phone: 801-899-6220
  • Fax: 855-402-2860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10858517-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number10858517-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: