Provider Demographics
NPI:1740756816
Name:JUAREZ, JACOB C (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2084 N. 1700 W.
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-773-8644
Mailing Address - Fax:
Practice Address - Street 1:2084 N. 1700 W.
Practice Address - Street 2:SUITE A
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-773-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11022394-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant