Healthcare Provider Details

I. General information

NPI: 1538896337
Provider Name (Legal Business Name): ALANNA BROOKE JORGENSEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 S 3000 E STE 310
SALT LAKE CITY UT
84121-6939
US

IV. Provider business mailing address

6360 S 3000 E STE 220
SALT LAKE CITY UT
84121-6924
US

V. Phone/Fax

Practice location:
  • Phone: 801-944-3144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number13052546-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: