MEDICARE: JACLYNN WILKERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	6632483-4405	UT

General Provider Information

NPI Number	:	1598213175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYNN WILKERSON

Provider Business Mailing Address
First Line	:	470 E 3900 S STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2332
Country	:	US
Telephone Number	:	801-747-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 E 3900 S STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2332
Country	:	US
Telephone Number	:	801-747-2800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2016
Last Update Date	:	09/13/2016

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