Healthcare Provider Details

I. General information

NPI: 1518906320
Provider Name (Legal Business Name): EILEEN KEENAN JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EILEEN GRAHAM JACKSON MD

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 E MAIN ST.
MORONI UT
84646
US

IV. Provider business mailing address

51 E MAIN ST.
MORONI UT
84646
US

V. Phone/Fax

Practice location:
  • Phone: 435-436-5250
  • Fax: 435-436-5262
Mailing address:
  • Phone: 435-283-4076
  • Fax: 435-283-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3687031205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: