Provider Demographics
NPI:1235474172
Name:FETZER, JACOB C (PA-C)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:C
Last Name:FETZER
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 1:762 E 500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2906
Mailing Address - Country:US
Mailing Address - Phone:801-574-6455
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 4A100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-585-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8421267-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant