Healthcare Provider Details

I. General information

NPI: 1144010380
Provider Name (Legal Business Name): JAKE ANTHONY LINDBERG MARANTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W COUGAR BLVD STE 801
PROVO UT
84604-3311
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-229-1054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14226711-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: