Provider Demographics
NPI:1982666475
Name:AVERY, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MCGLOTHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:144 S 500 E
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3580 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8812
Practice Address - Country:US
Practice Address - Phone:801-561-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT349010-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS62687Medicare UPIN
UT005568342Medicare ID - Type Unspecified3460 PIONEER PKWY, WVC
UT005568542Medicare ID - Type Unspecified630 MEDICAL DR, BOUNTIFUL
UT005568434Medicare ID - Type Unspecified3580 W 9000 S, W JORDAN
UT005567129Medicare ID - Type Unspecified1600 ANTELOPE DR, LAYTON