Provider Demographics
NPI:1770635195
Name:JEFFS, MARDIENE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MARDIENE
Middle Name:
Last Name:JEFFS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 W 250 N
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7020
Mailing Address - Country:US
Mailing Address - Phone:801-856-0909
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL DR
Practice Address - Street 2:210
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4968
Practice Address - Country:US
Practice Address - Phone:801-296-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102860-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant