Healthcare Provider Details

I. General information

NPI: 1154861524
Provider Name (Legal Business Name): JUSTIN JEFFRIES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 S SILICON WAY STE A
ST GEORGE UT
84770-7156
US

IV. Provider business mailing address

1492 S SILICON WAY STE A
ST GEORGE UT
84770-7156
US

V. Phone/Fax

Practice location:
  • Phone: 435-275-8911
  • Fax: 435-200-9442
Mailing address:
  • Phone: 435-275-8911
  • Fax: 435-200-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: