Provider Demographics
NPI:1114214442
Name:HAGEDORN, JEAN MORGAN (NP-C)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MORGAN
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIV OF UTAH
Mailing Address - Street 2:175 N. MEDICAL DRIVE EAST, 5TH FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-6908
Mailing Address - Fax:801-581-4385
Practice Address - Street 1:175 N. MEDICAL DRIVE EAST, 5TH FLOOR
Practice Address - Street 2:UNIV OF UTAH
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-6908
Practice Address - Fax:801-581-4385
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6830220-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP01016140OtherRAILROAD MEDICARE