Provider Demographics
NPI:1508040031
Name:WHITEHEAD, JENNIFER ANNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANNE
Last Name:WHITEHEAD
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 1:1092 PHEASANT TAIL DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5616
Mailing Address - Country:US
Mailing Address - Phone:801-816-9373
Mailing Address - Fax:801-816-9373
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-4100
Practice Address - Fax:801-662-4166
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369498-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant