Healthcare Provider Details

I. General information

NPI: 1710177357
Provider Name (Legal Business Name): BRUCE W JASPER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 03/04/2021
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST STE 810
MURRAY UT
84107-5705
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-9800
  • Fax:
Mailing address:
  • Phone: 801-507-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number001037
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number11569209-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: