Provider Demographics
NPI:1487866208
Name:VERNON, JEANETTE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 S. W. HOYTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COALVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84017
Mailing Address - Country:US
Mailing Address - Phone:435-336-2771
Mailing Address - Fax:
Practice Address - Street 1:82 NO 50 EAST
Practice Address - Street 2:
Practice Address - City:COALVILLE
Practice Address - State:UT
Practice Address - Zip Code:84017
Practice Address - Country:US
Practice Address - Phone:435-336-4403
Practice Address - Fax:435-336-5570
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT921066421206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant