Basic Information
| Provider Information | |||||||||
| NPI: | 1942390562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1674 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841101674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 210464-4402 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.