Provider Demographics
NPI:1932835311
Name:NIELSEN, JARED (PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 LILLYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3054
Mailing Address - Country:US
Mailing Address - Phone:801-915-3989
Mailing Address - Fax:
Practice Address - Street 1:985 LILLYWOOD LN
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-3054
Practice Address - Country:US
Practice Address - Phone:801-915-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13111589-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant