Provider Demographics
NPI:1538592142
Name:JORGENSEN EVANS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JORGENSEN EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 S 500 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:801-463-7415
Mailing Address - Fax:801-463-7341
Practice Address - Street 1:144 S 500 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1907
Practice Address - Country:US
Practice Address - Phone:801-463-7415
Practice Address - Fax:801-463-7341
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT267967-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner