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General NPI Number Information
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NPI Number | 1821934241
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Entity Type | Individual
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Provider Name | TIMOTHY JARED BLACK
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Gender | Male
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Dates
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Enumeration Date | 04/27/2026
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Last Update Date | 04/27/2026
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Provider Practice Location Address
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Address Line | 3742 W 2150 N
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City | LEHI
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State | UT
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Zip | 84048-7801
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Country | US
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Telephone | 385-220-6257
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Fax |
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Provider Business Mailing Address
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Address Line | 3288 E WHEAT FIELD LN
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City | EAGLE MOUNTAIN
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State | UT
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Zip | 84005-5527
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Country | US
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Telephone | 801-636-4913
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 8535186-4405
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License Number State | UT
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