Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | R4566 | TX |
N | 111NI0900X | Internist | R4566 | TX |
N | 207RC0200X | Critical Care Medicine | R4566 | TX |
Y | 207RP1001X | Pulmonary Disease | 12340843-1205 | UT |
N | 207RP1001X | Pulmonary Disease | R4566 | TX |
NPI | 1093151862 |
---|---|
Provider Name | Katie Rousseau Jeans |
First Address | West Jordan, UT 84084-4312 |
Second Address | Murray, UT 84107-6136 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2013 |
Last Update Date | 08/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
401850901 | (05) | TX |
401850902 | (05) | TX |
401850903 | (05) | TX |