Healthcare Provider Details

I. General information

NPI: 1871074310
Provider Name (Legal Business Name): JORGAN HOGGAN JACOBSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-8368
  • Fax:
Mailing address:
  • Phone: 801-587-8368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number10948626-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: