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1063039824

NPI Code Detail

MEDICARE: DENNIS N. JACKSON MD

MEDICARE: DENNIS N. JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PS0010X	Sports Medicine (Emergency Medicine) Physician	13323091-1205	UT
2	207P00000X	Emergency Medicine Physician	036172023	IL
3	207P00000X	Emergency Medicine Physician	13323091-1205	UT
4	207P00000X	Emergency Medicine Physician	27025	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J250139622810	OTHER		STATE OF MICHIGAN

General Provider Information

NPI Number	:	1063039824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS N. JACKSON MD

Provider Business Mailing Address
First Line	:	590 S WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-581-2121
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 S WAKARA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1200
Country	:	US
Telephone Number	:	801-581-2121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2020
Last Update Date	:	07/01/2026

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Directions to “ DENNIS N. JACKSON MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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