Provider Demographics
NPI:1821319377
Name:HATCH, JEFFERY JON (LPN)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:JON
Last Name:HATCH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 NORTH 200 WEST
Mailing Address - Street 2:
Mailing Address - City:KOOSHAREM
Mailing Address - State:UT
Mailing Address - Zip Code:84744
Mailing Address - Country:US
Mailing Address - Phone:435-231-1244
Mailing Address - Fax:
Practice Address - Street 1:184 NORTH 200 WEST
Practice Address - Street 2:
Practice Address - City:KOOSHAREM
Practice Address - State:UT
Practice Address - Zip Code:84744
Practice Address - Country:US
Practice Address - Phone:435-231-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT267947-3101164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT267947-3101Medicaid