Healthcare Provider Details

I. General information

NPI: 1477550515
Provider Name (Legal Business Name): JEFFREY MICHAEL COURSEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 S 400 E
SLC UT
84111-3302
US

IV. Provider business mailing address

461 S 400 E
SLC UT
84111-3302
US

V. Phone/Fax

Practice location:
  • Phone: 801-539-8617
  • Fax: 801-537-7238
Mailing address:
  • Phone: 801-539-8617
  • Fax: 801-537-7238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number101498-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: