=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265481980
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WASATCH UROLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 S 1100 E SUITE 301
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84102-1500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-532-1244
-----------------------------------------------------
Fax | 801-532-7277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 58201
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84158-0201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-532-1244
-----------------------------------------------------
Fax | 801-532-7277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JAMES CHRISTIAN JENSEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 801-532-1244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 1783141205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------