Provider Demographics
NPI:1922784933
Name:MADSEN, JEANNETT EILEEN (APRN)
Entity Type:Individual
Prefix:
First Name:JEANNETT
Middle Name:EILEEN
Last Name:MADSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 SIDEWINDER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7563
Mailing Address - Country:US
Mailing Address - Phone:435-658-9998
Mailing Address - Fax:
Practice Address - Street 1:2920 S JUDITH ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2649
Practice Address - Country:US
Practice Address - Phone:801-879-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT323449-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner