Provider Demographics
NPI:1609433572
Name:PALISOC, JENNYLYNN F (ARNP)
Entity Type:Individual
Prefix:DR
First Name:JENNYLYNN
Middle Name:F
Last Name:PALISOC
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FOOTHILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84148
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DRIVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2020-08-18
Deactivation Date:2019-07-22
Deactivation Code:
Reactivation Date:2019-07-29
Provider Licenses
StateLicense IDTaxonomies
WAAP60962323390200000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program