Provider Demographics
NPI:1124434501
Name:JAN CLEMENTS AGNP CORP
Entity type:Organization
Organization Name:JAN CLEMENTS AGNP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:801-796-7961
Mailing Address - Street 1:66 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2637
Mailing Address - Country:US
Mailing Address - Phone:801-796-7961
Mailing Address - Fax:801-796-1101
Practice Address - Street 1:66 E STATE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2637
Practice Address - Country:US
Practice Address - Phone:801-796-7961
Practice Address - Fax:801-796-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1938944405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU00008597Medicare UPIN
UT1124449285Medicare PIN