Provider Demographics
NPI:1396262424
Name:FORD, JANE KOFFORD (APRN)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:KOFFORD
Last Name:FORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JANIE
Other - Middle Name:KOFFORD
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:5848 S FASHION BLVD
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6157
Mailing Address - Country:US
Mailing Address - Phone:801-641-0048
Mailing Address - Fax:
Practice Address - Street 1:5848 S FASHION BLVD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6157
Practice Address - Country:US
Practice Address - Phone:801-314-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT203534-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner