Healthcare Provider Details

I. General information

NPI: 1659314706
Provider Name (Legal Business Name): JENNIFER W ANDERSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER W ANDERSON FNP

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8006 S MOUNTAIN OAKS DR
SALT LAKE CITY UT
84121-5921
US

IV. Provider business mailing address

PO BOX 150173
OGDEN UT
84415-0173
US

V. Phone/Fax

Practice location:
  • Phone: 801-634-5366
  • Fax:
Mailing address:
  • Phone: 801-479-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number198045-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: