Healthcare Provider Details

I. General information

NPI: 1558109504
Provider Name (Legal Business Name): JODI LYN PUTNAM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 02/28/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 NORTH MAIN ST STE 1B
SPANISH FORK UT
84660
US

IV. Provider business mailing address

1416 NORTH MAIN ST STE 1B
SPANISH FORK UT
84660
US

V. Phone/Fax

Practice location:
  • Phone: 385-518-0403
  • Fax: 385-518-0466
Mailing address:
  • Phone: 385-518-0403
  • Fax: 385-518-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7992533-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7992533-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: