Healthcare Provider Details

I. General information

NPI: 1760331540
Provider Name (Legal Business Name): JESUS ALEJANDRO CARABALLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2026
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S CHIPETA WAY STE 22
SALT LAKE CITY UT
84108-1234
US

IV. Provider business mailing address

3624 W 7950 S
WEST JORDAN UT
84088-4426
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: