Healthcare Provider Details

I. General information

NPI: 1427269166
Provider Name (Legal Business Name): JACE H FERGUSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3935 N 75 W
HYDE PARK UT
84318-4111
US

IV. Provider business mailing address

3935 N 75 W
HYDE PARK UT
84318-4111
US

V. Phone/Fax

Practice location:
  • Phone: 435-563-6363
  • Fax: 435-563-0293
Mailing address:
  • Phone: 435-563-6363
  • Fax: 435-563-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number5242118-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: