Basic Information
| Provider Information | |||||||||
| NPI: | 1023502093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JERGENSEN | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 S ARAPEEN DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816393 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 S ARAPEEN DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816393 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2018 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2018020285 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 2020029411 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 12751738-1205 | UT | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 12751738-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.