Healthcare Provider Details

I. General information

NPI: 1336130889
Provider Name (Legal Business Name): JESSE A JORGENSEN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 W ANTELOPE DR SUITE 100
LAYTON UT
84041-1160
US

IV. Provider business mailing address

1566 E 1700 S
SLC UT
84105
US

V. Phone/Fax

Practice location:
  • Phone: 801-927-1632
  • Fax: 801-927-1591
Mailing address:
  • Phone: 801-773-8644
  • Fax: 775-246-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA907
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17883
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6124415-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: