Basic Information
Provider Information | |||||||||
NPI: | 1700946589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JONSON | ||||||||
FirstName: | JAN | ||||||||
MiddleName: | CHRISTER | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: |   | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8018124673 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Practice Location | |||||||||
Address1: | 1125 BLACKHAWK BLVD | ||||||||
Address2: | CENTRAL UTAH CLINIC FAMILY MEDICINE | ||||||||
City: | MT PLEASANT | ||||||||
State: | UT | ||||||||
PostalCode: | 84647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4354622044 | ||||||||
FaxNumber: | 4354622043 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2006 | ||||||||
LastUpdateDate: | 07/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1017171206 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 529496984001 | 05 | UT |   | MEDICAID |