Healthcare Provider Details

I. General information

NPI: 1962418210
Provider Name (Legal Business Name): BRENT D JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S HIGHWAY 99 #3
FILLMORE UT
84631-5134
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-743-5555
  • Fax:
Mailing address:
  • Phone: 435-743-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1638281205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: