Provider Demographics
NPI:1912035221
Name:HERZOG, JESSICA LAUREN MADERT (MD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LAUREN MADERT
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3397 N 1200 E STE 103
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3262
Mailing Address - Country:US
Mailing Address - Phone:801-797-0877
Mailing Address - Fax:801-290-8141
Practice Address - Street 1:3397 N 1200 E STE 103
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3262
Practice Address - Country:US
Practice Address - Phone:801-797-0877
Practice Address - Fax:801-290-8141
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8450572-1205208000000X, 208D00000X
PAMD449593208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA420536OtherUPMC
PA2983938OtherHIGHMARK BLUE SHIELD
PA102859700Medicaid
PA313986FLTMedicare PIN