Provider Demographics
NPI:1578115903
Name:MCCULLOUGH, JENNIFER RENEA (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEA
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2621 S 3270 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1119
Mailing Address - Country:US
Mailing Address - Phone:385-261-2737
Mailing Address - Fax:801-746-0420
Practice Address - Street 1:4745 S 3200 W
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2822
Practice Address - Country:US
Practice Address - Phone:801-964-6214
Practice Address - Fax:801-746-0420
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5643351-3102163W00000X
UT5643351-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse