Healthcare Provider Details

I. General information

NPI: 1225693229
Provider Name (Legal Business Name): JENNIFER MAKUAKANE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 W STATE RD
PLEASANT GROVE UT
84062-5015
US

IV. Provider business mailing address

11026 N 5730 W
HIGHLAND UT
84003-9425
US

V. Phone/Fax

Practice location:
  • Phone: 385-202-3278
  • Fax:
Mailing address:
  • Phone: 385-202-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number369906-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: