Healthcare Provider Details

I. General information

NPI: 1396289799
Provider Name (Legal Business Name): JEFFERSON M ALLEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S 1300 W
PLEASANT GROVE UT
84062-3761
US

IV. Provider business mailing address

360 S 1300 W
PLEASANT GROVE UT
84062-3761
US

V. Phone/Fax

Practice location:
  • Phone: 385-440-1400
  • Fax: 801-845-9965
Mailing address:
  • Phone: 385-440-1400
  • Fax: 801-845-9965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10174452-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10174452-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: