Healthcare Provider Details

I. General information

NPI: 1134991789
Provider Name (Legal Business Name): JAYLENE DALLEY MORTENSEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 W RIVER SIDE LN
SPANISH FORK UT
84660-5014
US

IV. Provider business mailing address

347 W RIVER SIDE LN
SPANISH FORK UT
84660-5014
US

V. Phone/Fax

Practice location:
  • Phone: 435-773-3458
  • Fax:
Mailing address:
  • Phone: 435-773-3458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number6370779-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: