Basic Information
| Provider Information | |||||||||
| NPI: | 1871743369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORENSEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7321 BALMER ST | ||||||||
| Address2: | BLDG 570 | ||||||||
| City: | HILL AFB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840565012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876705 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 CIRCLE OF HOPE | ||||||||
| Address2: | CLINIC 3A 2E | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841125550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015850100 | ||||||||
| FaxNumber: | 8015817532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2008 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7132130-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 71321301206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.