Provider Demographics
NPI:1669826749
Name:JTC ADVANCED PRACTICE
Entity Type:Organization
Organization Name:JTC ADVANCED PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSONTALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-669-3425
Mailing Address - Street 1:270 S 1060 W
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1600
Mailing Address - Country:US
Mailing Address - Phone:801-669-3425
Mailing Address - Fax:
Practice Address - Street 1:270 S 1060 W
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1600
Practice Address - Country:US
Practice Address - Phone:801-669-3425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8052012-0162261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center