Provider Demographics
NPI:1912632175
Name:PACK, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2573 E 6600 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2349
Mailing Address - Country:US
Mailing Address - Phone:801-520-3976
Mailing Address - Fax:
Practice Address - Street 1:6233 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84121-2125
Practice Address - Country:US
Practice Address - Phone:801-520-3976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy