Healthcare Provider Details

I. General information

NPI: 1467775403
Provider Name (Legal Business Name): JEFFREY MICHAEL POLLOCK P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8822 S REDWOOD RD SUITE C111
WEST JORDAN UT
84088-9336
US

IV. Provider business mailing address

7795 TINAMOUS RD
EAGLE MOUNTAIN UT
84005-4187
US

V. Phone/Fax

Practice location:
  • Phone: 801-685-2730
  • Fax:
Mailing address:
  • Phone: 801-671-7456
  • Fax: 801-877-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number58256401206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: