Provider Demographics
NPI:1093151862
Name:JEANS, KATIE ROUSSEAU (MD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ROUSSEAU
Last Name:JEANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MAHALI
Other - Last Name:ROUSSEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7181 S CAMPUS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4312
Mailing Address - Country:US
Mailing Address - Phone:801-965-3505
Mailing Address - Fax:
Practice Address - Street 1:5801 S FASHION BLVD STE 280
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6136
Practice Address - Country:US
Practice Address - Phone:801-268-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4566207R00000X, 207RC0200X, 207RP1001X
UT12340843-1205207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX401850901Medicaid
TX401850902Medicaid
TX401850903Medicaid