Healthcare Provider Details

I. General information

NPI: 1922677541
Provider Name (Legal Business Name): JESSICA PONCE HIDALGO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5063 S COTTONWOOD ST STE 100
MURRAY UT
84107-6772
US

IV. Provider business mailing address

1546 UNIVERSITY VLG
SALT LAKE CITY UT
84108-3524
US

V. Phone/Fax

Practice location:
  • Phone: 323-474-1037
  • Fax:
Mailing address:
  • Phone: 323-474-1037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: