Provider Demographics
NPI:1619606340
Name:WESTERN, JEFFREY (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:WESTERN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9387 S KOCH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4688
Mailing Address - Country:US
Mailing Address - Phone:801-358-0949
Mailing Address - Fax:
Practice Address - Street 1:13454 S MONARCH MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-2562
Practice Address - Country:US
Practice Address - Phone:801-254-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12888596-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist