Healthcare Provider Details

I. General information

NPI: 1578320891
Provider Name (Legal Business Name): JACOB ANTHONY WOODS MSN, PMHNP-BC, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 E VINE ST
MURRAY UT
84107-5549
US

IV. Provider business mailing address

14073 S CHARDONNAY WAY
BLUFFDALE UT
84065-3857
US

V. Phone/Fax

Practice location:
  • Phone: 801-436-6556
  • Fax:
Mailing address:
  • Phone: 315-854-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number9471119-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9471119-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: