Provider Demographics
NPI:1962070102
Name:WALSH, JEFFREY SCOTT
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:WALSH
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 1:542 E 1600 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4016
Mailing Address - Country:US
Mailing Address - Phone:801-979-4077
Mailing Address - Fax:
Practice Address - Street 1:542 E 1600 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4016
Practice Address - Country:US
Practice Address - Phone:801-979-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10676959-3102163WG0000X
UT10676959-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice