Basic Information
| Provider Information | |||||||||
| NPI: | 1164683959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COMSTOCK | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 S 500 E | ||||||||
| Address2: | 600 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N MARIO CAPPECHI DR | ||||||||
| Address2: | PRIMARY CHILDRENS MEDICAL CENTER DEPT OF PATHOLOGY | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016622164 | ||||||||
| FaxNumber: | 8016622165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0213X | 6025574-1205 | UT | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 208000000X | 6025574-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics | 207ZP0102X | 60255741205 | UT | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.