Healthcare Provider Details

I. General information

NPI: 1245124445
Provider Name (Legal Business Name): JIENEVE MARIE CORDOVA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E 1430 N
OREM UT
84057-2700
US

IV. Provider business mailing address

70 E 1430 N
OREM UT
84057-2700
US

V. Phone/Fax

Practice location:
  • Phone: 435-513-0356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9717191-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: