Healthcare Provider Details

I. General information

NPI: 1639909773
Provider Name (Legal Business Name): KATHY LANAE JACOBS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S 100 W
LAYTON UT
84041-5356
US

IV. Provider business mailing address

619 E 2475 N
NORTH OGDEN UT
84414-2824
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9796796-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: