Provider Demographics
NPI:1538147277
Name:POORE', JON T (BSRN)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:T
Last Name:POORE'
Suffix:
Gender:M
Credentials:BSRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S 200 W
Mailing Address - Street 2:#C507
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1828
Mailing Address - Country:US
Mailing Address - Phone:801-580-7624
Mailing Address - Fax:
Practice Address - Street 1:500 SOUTH
Practice Address - Street 2:530 EAST
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-538-2057
Practice Address - Fax:801-596-2515
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3306403102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3306403102Medicare UPIN