Provider Demographics
NPI:1538391339
Name:AUDREY JANTZEN, M.D. PLLC
Entity type:Organization
Organization Name:AUDREY JANTZEN, M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JANTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-229-1054
Mailing Address - Street 1:3685 N 100 E
Mailing Address - Street 2:SUITE A
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4594
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3685 N 100 E
Practice Address - Street 2:SUITE A
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4594
Practice Address - Country:US
Practice Address - Phone:801-229-1954
Practice Address - Fax:801-426-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT66542191205261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty