Healthcare Provider Details

I. General information

NPI: 1164683959
Provider Name (Legal Business Name): JESSICA COMSTOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPPECHI DR PRIMARY CHILDRENS MEDICAL CENTER DEPT OF PATHOLOGY
SALT LAKE CITY UT
84113
US

IV. Provider business mailing address

127 S 500 E 600
SALT LAKE CITY UT
84102-1959
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-2164
  • Fax: 801-662-2165
Mailing address:
  • Phone: 801-587-6336
  • Fax: 801-715-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number60255741205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number6025574-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6025574-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: