Healthcare Provider Details

I. General information

NPI: 1558146597
Provider Name (Legal Business Name): JODI LYN OTT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI LYN OTT FNP

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3133 E CEDAR PASS RD
EAGLE MOUNTAIN UT
84005-4146
US

IV. Provider business mailing address

3133 E CEDAR PASS RD
EAGLE MOUNTAIN UT
84005-4146
US

V. Phone/Fax

Practice location:
  • Phone: 435-531-1066
  • Fax:
Mailing address:
  • Phone: 435-531-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6065166-8900
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6065166-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: