Provider Demographics
NPI:1376015065
Name:GARRITSON, JORDAN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:GARRITSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 S COTTONWOOD ST STE 420
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6769
Mailing Address - Country:US
Mailing Address - Phone:801-507-1650
Mailing Address - Fax:801-507-1699
Practice Address - Street 1:5169 S COTTONWOOD ST STE 420
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6769
Practice Address - Country:US
Practice Address - Phone:801-507-1650
Practice Address - Fax:801-507-1699
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10997512-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1376015065Medicaid