Provider Demographics
NPI:1558146597
Name:WILLIS, JODI LYN (FNP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:LYN
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:3133 E CEDAR PASS RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4146
Mailing Address - Country:US
Mailing Address - Phone:435-531-1066
Mailing Address - Fax:
Practice Address - Street 1:3133 E CEDAR PASS RD
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-4146
Practice Address - Country:US
Practice Address - Phone:435-531-1066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6065166-4405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine