Healthcare Provider Details

I. General information

NPI: 1619618774
Provider Name (Legal Business Name): JAMIE HENRIKSEN KOWALK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4738 W VERMILLION DR
SOUTH JORDAN UT
84009-4798
US

IV. Provider business mailing address

4738 W VERMILLION DR
SOUTH JORDAN UT
84009-4798
US

V. Phone/Fax

Practice location:
  • Phone: 702-366-6990
  • Fax:
Mailing address:
  • Phone: 702-366-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number194216883
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: