Healthcare Provider Details

I. General information

NPI: 1396918462
Provider Name (Legal Business Name): LU ANN JACOBS-PETERSON APRN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/25/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 N 400 E STE 205
TOOELE UT
84074-3413
US

IV. Provider business mailing address

14540 S MAJESTIC OAKS LN
HERRIMAN UT
84096-3645
US

V. Phone/Fax

Practice location:
  • Phone: 435-882-8111
  • Fax: 435-882-2111
Mailing address:
  • Phone: 801-232-1998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number219855-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number219855-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: