Healthcare Provider Details

I. General information

NPI: 1952080756
Provider Name (Legal Business Name): JACOB HOLT RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5983 S REDWOOD RD
TAYLORSVILLE UT
84123-5261
US

IV. Provider business mailing address

5983 S REDWOOD RD
TAYLORSVILLE UT
84123-5261
US

V. Phone/Fax

Practice location:
  • Phone: 385-800-3015
  • Fax:
Mailing address:
  • Phone: 385-800-3015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number11004708-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: