MEDICARE: JESSICA LATHAM PA-C, MPAS

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	363AM0700X	Medical Physician Assistant	7432864-1206	UT

General Provider Information

NPI Number	:	1619203015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LATHAM PA-C, MPAS

Provider Business Mailing Address
First Line	:	3590 W 9000 S STE 240
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-8864
Country	:	US
Telephone Number	:	801-352-8373
Fax Number	:	801-352-8459

Provider Business Practice Location Address
First Line	:	344 E 100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1700
Country	:	US
Telephone Number	:	801-322-3222
Fax Number	:

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

Provider Enumeration Date	:	10/20/2009
Last Update Date	:	06/30/2023

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