Provider Demographics
NPI:1548680184
Name:WEST VALLEY DERMATOLOGY
Entity type:Organization
Organization Name:WEST VALLEY DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:385-377-0212
Mailing Address - Street 1:4133 PIONEER PKWY
Mailing Address - Street 2:STE 120
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2050
Mailing Address - Country:US
Mailing Address - Phone:801-966-1403
Mailing Address - Fax:801-964-6478
Practice Address - Street 1:4133 PIONEER PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2050
Practice Address - Country:US
Practice Address - Phone:801-966-1403
Practice Address - Fax:801-964-6478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8963761-1204207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty