Healthcare Provider Details

I. General information

NPI: 1255434296
Provider Name (Legal Business Name): DAVID B JACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 02/01/2022
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 E KIMBALLS LN STE 260
DRAPER UT
84020-5009
US

IV. Provider business mailing address

PO BOX 198560
ATLANTA GA
30384-1721
US

V. Phone/Fax

Practice location:
  • Phone: 801-545-8480
  • Fax: 801-253-1602
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number168941-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: