Healthcare Provider Details

I. General information

NPI: 1164925467
Provider Name (Legal Business Name): JASON B DICKERSON DPM LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 S FASHION BLVD STE 120
MURRAY UT
84107-8115
US

IV. Provider business mailing address

5801 S FASHION BLVD STE 120
MURRAY UT
84107-8115
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-1391
  • Fax:
Mailing address:
  • Phone: 801-261-1391
  • Fax: 801-261-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number4830364-0501
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY LOFTHOUSE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 530-925-6027