Provider Demographics
NPI:1659314706
Name:ANDERSON, JENNIFER W (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:W
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 150173
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0173
Mailing Address - Country:US
Mailing Address - Phone:801-479-0601
Mailing Address - Fax:
Practice Address - Street 1:8006 S MOUNTAIN OAKS DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-5921
Practice Address - Country:US
Practice Address - Phone:801-634-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT198045-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005812401Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
UT005812401Medicare UPIN