Provider Demographics
NPI:1023549268
Name:KINGDON, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:KINGDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 EAGLEPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2643
Mailing Address - Country:US
Mailing Address - Phone:801-638-7785
Mailing Address - Fax:
Practice Address - Street 1:652 EAGLEPOINTE DR
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-2643
Practice Address - Country:US
Practice Address - Phone:801-638-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119740-2401405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional