Basic Information
| Provider Information | |||||||||
| NPI: | 1265865125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETROVICH | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2621 S 3270 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841191119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3852612737 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Practice Location | |||||||||
| Address1: | 4745 S 3200 W | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019646214 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10964121-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 74-2412898 | 05 | UT | MEDICAID |