Healthcare Provider Details

I. General information

NPI: 1710787502
Provider Name (Legal Business Name): JESSICA QUINAGORAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

1409 E 2100 S UNIT 1
SALT LAKE CITY UT
84105-3724
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 469-371-9748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14298626-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: