Basic Information
| Provider Information | |||||||||
| NPI: | 1538592142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORGENSEN EVANS | ||||||||
| FirstName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 S 500 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
| FaxNumber: | 8014637341 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 S 500 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
| FaxNumber: | 8014637341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2013 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 267967-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.