Provider Demographics
NPI:1568497634
Name:TITTENSOR, JENNIFER J (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:TITTENSOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3550 N UNIVERSITY AVE
Mailing Address - Street 2:STE 250
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:801-374-9690
Practice Address - Street 1:3550 N UNIVERSITY AVE
Practice Address - Street 2:STE 250
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-374-9625
Practice Address - Fax:801-374-9690
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT60750371205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870516264009Medicaid