Provider Demographics
NPI:1932733771
Name:SHUMWAY, JORDAN LOVELL (PA, ATC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LOVELL
Last Name:SHUMWAY
Suffix:
Gender:M
Credentials:PA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 W 11625 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7936
Mailing Address - Country:US
Mailing Address - Phone:385-208-8376
Mailing Address - Fax:
Practice Address - Street 1:333 N 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-1215
Practice Address - Country:US
Practice Address - Phone:801-463-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UTBOC3732772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant