Provider Demographics
NPI:1679901169
Name:WIGHT, JENNIFER AILEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:AILEEN
Last Name:WIGHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:AILEEN
Other - Last Name:WIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3535 E BENGAL BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5901
Mailing Address - Country:US
Mailing Address - Phone:801-718-0582
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 440
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6774
Practice Address - Country:US
Practice Address - Phone:801-507-3915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7984091-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant