Healthcare Provider Details

I. General information

NPI: 1114386620
Provider Name (Legal Business Name): JACOB JACKSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE JACKSON DC

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 S FASHION BLVD SUITE 210
MURRAY UT
84107-6159
US

IV. Provider business mailing address

5801 S FASHION BLVD SUITE 210
MURRAY UT
84107-6159
US

V. Phone/Fax

Practice location:
  • Phone: 801-923-2882
  • Fax: 801-506-0134
Mailing address:
  • Phone: 801-923-2882
  • Fax: 801-506-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number9690256-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: