Provider Demographics
NPI:1053108332
Name:ANDERSON, JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:KUNZELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:127 S 500 E STE 220
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 S 500 E STE 220
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1982
Practice Address - Country:US
Practice Address - Phone:801-581-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program