=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881375962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA T JACOBS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2023
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 668 E 12225 S STE 204
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-8385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-899-6220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 668 E 12225 S STE 204
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-8385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-899-6220
-----------------------------------------------------
Fax | 855-402-2860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 10858517-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WM0705X
-----------------------------------------------------
Taxonomy Name | Medical-Surgical Registered Nurse
-----------------------------------------------------
License Number | 10858517-3102
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------