Healthcare Provider Details

I. General information

NPI: 1477322063
Provider Name (Legal Business Name): JORDAN ROBERT COWAN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2023
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 W ANTELOPE DR
LAYTON UT
84041-1143
US

IV. Provider business mailing address

1777 N CELIA WAY
LAYTON UT
84041-4904
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-4840
  • Fax:
Mailing address:
  • Phone: 801-815-8897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6179909-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: