Individual
JACOB CHURCH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1055 N 500 W STE 121, PROVO, UT 84604-3305
(013) 737-3508
(801) 812-5401
Mailing address
1055 N 500 W, PROVO, UT 84604-3305
(801) 354-8225
(801) 418-0941
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
06/10/2022
Last updated
06/10/2022
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