Provider Demographics
NPI:1396289799
Name:ALLEN, JEFFERSON M (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:M
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 S 1560 W STE B
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2361
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:245 S 1060 W
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1606
Practice Address - Country:US
Practice Address - Phone:385-306-1222
Practice Address - Fax:385-243-3129
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10174452-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical