Healthcare Provider Details

I. General information

NPI: 1679934830
Provider Name (Legal Business Name): JED ATKINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S UNIVERSITY AVE SUITE 3200
PROVO UT
84601-4427
US

IV. Provider business mailing address

151 S UNIVERSITY AVE SUITE 3200
PROVO UT
84601-4427
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-7652
  • Fax:
Mailing address:
  • Phone: 801-851-7652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4892683-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: