Healthcare Provider Details

I. General information

NPI: 1144668591
Provider Name (Legal Business Name): JORDAN WYLER JOHNSEN FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N MAIN ST STE 103
KAYSVILLE UT
84037-1272
US

IV. Provider business mailing address

254 W 5400 S
WASHINGTON TERRACE UT
84405-6835
US

V. Phone/Fax

Practice location:
  • Phone: 801-876-3749
  • Fax: 801-876-3697
Mailing address:
  • Phone: 801-361-6787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6212698-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: