Healthcare Provider Details

I. General information

NPI: 1487944096
Provider Name (Legal Business Name): JARED ALAN JOHNSTUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 E FORT UNION BLVD STE 105
MIDVALE UT
84047-5529
US

IV. Provider business mailing address

623 E FORT UNION BLVD STE 105
MIDVALE UT
84047-5529
US

V. Phone/Fax

Practice location:
  • Phone: 385-412-1660
  • Fax:
Mailing address:
  • Phone: 385-412-1660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8134352-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number8134352-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036.160773
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036.160773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: