Healthcare Provider Details

I. General information

NPI: 1295745651
Provider Name (Legal Business Name): JANE H. RICKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 SUNNYSIDE AVE
SALT LAKE CITY UT
84105-1631
US

IV. Provider business mailing address

PO BOX 1557
DRAPER UT
84020-1557
US

V. Phone/Fax

Practice location:
  • Phone: 801-891-4875
  • Fax:
Mailing address:
  • Phone: 801-891-4875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number184829-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: