Healthcare Provider Details

I. General information

NPI: 1619203015
Provider Name (Legal Business Name): JESSICA LATHAM PA-C, MPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 E 100 S
SALT LAKE CITY UT
84111-1700
US

IV. Provider business mailing address

3590 W 9000 S STE 240
WEST JORDAN UT
84088-8864
US

V. Phone/Fax

Practice location:
  • Phone: 801-322-3222
  • Fax:
Mailing address:
  • Phone: 801-352-8373
  • Fax: 801-352-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7432864-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: