Provider Demographics
NPI:1982299301
Name:MINER, JENNICA MARLEE
Entity type:Individual
Prefix:
First Name:JENNICA
Middle Name:MARLEE
Last Name:MINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNICA
Other - Middle Name:MARLEE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:348 E 4500 S
Mailing Address - Street 2:STE 220
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8524
Mailing Address - Country:US
Mailing Address - Phone:801-577-7055
Mailing Address - Fax:
Practice Address - Street 1:620 S 400 E STE 404
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7065
Practice Address - Country:US
Practice Address - Phone:435-656-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104167604405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily