Healthcare Provider Details

I. General information

NPI: 1497682926
Provider Name (Legal Business Name): KEIANU JAMESON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 S 1000 E
CLEARFIELD UT
84015-1646
US

IV. Provider business mailing address

1550 S 1000 E
CLEARFIELD UT
84015-1646
US

V. Phone/Fax

Practice location:
  • Phone: 385-456-6275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: