Provider Demographics
NPI:1821733080
Name:ANDERSON, JACOB GLEN (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:GLEN
Last Name:ANDERSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 N MARIO CAPECCHI DR # 4B056
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1125
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:81 N MARIO CAPECCHI DR # 4B056
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1125
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X390200000X
UT14210863-12052080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program