Healthcare Provider Details

I. General information

NPI: 1821525965
Provider Name (Legal Business Name): JASON MACKAY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 E DRAPER PKWY
DRAPER UT
84020-9096
US

IV. Provider business mailing address

1147 E DRAPER PKWY
DRAPER UT
84020-9096
US

V. Phone/Fax

Practice location:
  • Phone: 801-916-9555
  • Fax:
Mailing address:
  • Phone: 714-334-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10650496-9934
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number10650496-9934
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number10650496-9934
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number10650496-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: