Healthcare Provider Details

I. General information

NPI: 1669704045
Provider Name (Legal Business Name): JEREMIAH JORGENSEN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 06/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 W 9000 S SUITE 405
WEST JORDAN UT
84088-5710
US

IV. Provider business mailing address

6460 MEDICAL CENTER ST STE 350
LAS VEGAS NV
89148-2423
US

V. Phone/Fax

Practice location:
  • Phone: 801-568-3480
  • Fax: 801-568-3482
Mailing address:
  • Phone: 702-255-6647
  • Fax: 702-933-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4597
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2046
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8152398-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: