Healthcare Provider Details

I. General information

NPI: 1821934241
Provider Name (Legal Business Name): TIMOTHY JARED BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3742 W 2150 N
LEHI UT
84048-7801
US

IV. Provider business mailing address

3288 E WHEAT FIELD LN
EAGLE MOUNTAIN UT
84005-5527
US

V. Phone/Fax

Practice location:
  • Phone: 385-220-6257
  • Fax:
Mailing address:
  • Phone: 801-636-4913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8535186-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: