Healthcare Provider Details

I. General information

NPI: 1710508429
Provider Name (Legal Business Name): JEREMY E GILLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 S 500 E
OGDEN UT
84405-6905
US

IV. Provider business mailing address

2797 W 2100 N
CLINTON UT
84015-7693
US

V. Phone/Fax

Practice location:
  • Phone: 801-831-2387
  • Fax:
Mailing address:
  • Phone: 801-831-2387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9532686
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9640421-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: