Healthcare Provider Details

I. General information

NPI: 1932733771
Provider Name (Legal Business Name): JORDAN LOVELL SHUMWAY PA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 300 W
SALT LAKE CITY UT
84103-1215
US

IV. Provider business mailing address

2326 W 11625 S
RIVERTON UT
84095-7936
US

V. Phone/Fax

Practice location:
  • Phone: 801-463-7415
  • Fax:
Mailing address:
  • Phone: 385-208-8376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberBOC373277
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12227421-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: