Healthcare Provider Details

I. General information

NPI: 1548657703
Provider Name (Legal Business Name): JACQUELYN M. SIMONIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E RM 4C104
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E RM 4C104
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1686
  • Fax:
Mailing address:
  • Phone: 801-585-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number209357
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number11849354-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number11849354-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: