Healthcare Provider Details

I. General information

NPI: 1053560789
Provider Name (Legal Business Name): SUSAN JESPERSEN AGRES DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5275 ADAMS AVE PKWY SUITE A
OGDEN UT
84405-6748
US

IV. Provider business mailing address

1322 32ND ST
OGDEN UT
84403-0902
US

V. Phone/Fax

Practice location:
  • Phone: 801-430-8406
  • Fax:
Mailing address:
  • Phone: 801-430-8406
  • Fax: 801-393-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN004009
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number7259622-0504
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: