Healthcare Provider Details

I. General information

NPI: 1578115903
Provider Name (Legal Business Name): JENNIFER RENEA MCCULLOUGH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 S 3200 W
TAYLORSVILLE UT
84129-2822
US

IV. Provider business mailing address

2621 S 3270 W
WEST VALLEY CITY UT
84119-1119
US

V. Phone/Fax

Practice location:
  • Phone: 801-964-6214
  • Fax: 801-746-0420
Mailing address:
  • Phone: 385-261-2737
  • Fax: 801-746-0420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number5643351-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number5643351-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: