Provider Demographics
NPI:1497908008
Name:MATHIS, JARED HARVEY
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:HARVEY
Last Name:MATHIS
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 1:3181 W 9000 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5610
Mailing Address - Country:US
Mailing Address - Phone:801-569-5520
Mailing Address - Fax:801-352-5951
Practice Address - Street 1:3181 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5610
Practice Address - Country:US
Practice Address - Phone:801-569-5520
Practice Address - Fax:801-352-5951
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT71505961206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant