Basic Information
Provider Information | |||||||||
NPI: | 1780236109 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEILSON | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7181 S CAMPUS VIEW DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | WEST JORDAN | ||||||||
State: | UT | ||||||||
PostalCode: | 840844312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019653505 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12391 S 4000 W | ||||||||
Address2: |   | ||||||||
City: | RIVERTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840967012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013021700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2019 | ||||||||
LastUpdateDate: | 05/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9523151-4405 | UT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 9523151-3102 | UT | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0200X | 9523151-4405 | UT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP2300X | 9523151-4405 | UT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | 9523151-4405 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.