Basic Information
| Provider Information | |||||||||
| NPI: | 1710323860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | KATHARINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACOBSON | ||||||||
| OtherFirstName: | ANNE | ||||||||
| OtherMiddleName: | KATHARINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2013 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9127581-1204 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.