Healthcare Provider Details

I. General information

NPI: 1275926149
Provider Name (Legal Business Name): CALEB R JACKSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S MAIN ST
ALPINE UT
84004-2008
US

IV. Provider business mailing address

375 S MAIN ST
ALPINE UT
84004-2008
US

V. Phone/Fax

Practice location:
  • Phone: 801-891-5788
  • Fax:
Mailing address:
  • Phone: 801-891-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347183-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: