Provider Demographics
NPI:1831515246
Name:GRIFFIN, JENESSA WILSON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENESSA
Middle Name:WILSON
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENESSA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1055 N 500 W ATT: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W STE 101
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-4366
Practice Address - Fax:801-429-8191
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6044363A00000X
UT11734006-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant