Healthcare Provider Details

I. General information

NPI: 1366963928
Provider Name (Legal Business Name): JEDEDIAH DOUGLAS KOWALSKI APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 W DAYBREAK PKWY
SOUTH JORDAN UT
84009-5994
US

IV. Provider business mailing address

856 W RONTANO CT
MIDVALE UT
84047-1605
US

V. Phone/Fax

Practice location:
  • Phone: 801-656-7647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7964951-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: