Healthcare Provider Details

I. General information

NPI: 1205182219
Provider Name (Legal Business Name): JENNIFER GYLLENSKOG SKOUSEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL BLVD # 119
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

7652 S 2050 E
SOUTH WEBER UT
84405-9755
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-603-1232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number309750-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: