Provider Demographics
NPI:1740394972
Name:HOLLIS, JEAN S (PAC)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:S
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 5350 S
Mailing Address - Street 2:SUITE 335
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6946
Mailing Address - Country:US
Mailing Address - Phone:801-475-8600
Mailing Address - Fax:801-771-1330
Practice Address - Street 1:425 E 5350 S
Practice Address - Street 2:SUITE 335
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6946
Practice Address - Country:US
Practice Address - Phone:801-475-8600
Practice Address - Fax:801-771-1330
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003282363A00000X
UT268114-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00474004OtherRR MEDICARE
UTP00474004OtherRR MEDICARE
UT000062779Medicare PIN