MEDICARE: DR. JESSICA PONCE HIDALGO PHD

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	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1922677541
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA PONCE HIDALGO PHD

Provider Business Mailing Address
First Line	:	1546 UNIVERSITY VLG
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3524
Country	:	US
Telephone Number	:	323-474-1037
Fax Number	:

Provider Business Practice Location Address
First Line	:	5063 S COTTONWOOD ST STE 100
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-6772
Country	:	US
Telephone Number	:	323-474-1037
Fax Number	:

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

Provider Enumeration Date	:	06/18/2021
Last Update Date	:	06/23/2021

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