Basic Information
| Provider Information | |||||||||
| NPI: | 1962510016 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIRICKO | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017796200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD | ||||||||
| Address2: | STE #4815 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013878350 | ||||||||
| FaxNumber: | 8013878355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 02/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 56726168905 | UT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 5672616-1205 | UT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.