Provider Demographics
NPI:1093554636
Name:PENROSE, JEFF LYNN
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:LYNN
Last Name:PENROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1615
Mailing Address - Country:US
Mailing Address - Phone:801-856-7799
Mailing Address - Fax:
Practice Address - Street 1:392 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1615
Practice Address - Country:US
Practice Address - Phone:801-856-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator