Healthcare Provider Details

I. General information

NPI: 1962650184
Provider Name (Legal Business Name): JEDEDIAH S BRISCOE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 E 100 S
SALT LAKE CITY UT
84102-1501
US

IV. Provider business mailing address

1060 E 100 S
SALT LAKE CITY UT
84102-1501
US

V. Phone/Fax

Practice location:
  • Phone: 801-350-4110
  • Fax:
Mailing address:
  • Phone: 801-350-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334170-4408
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: