Healthcare Provider Details

I. General information

NPI: 1598557753
Provider Name (Legal Business Name): JORDAN SPENCER ERICKSEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 S 100 W
PAYSON UT
84651-2865
US

IV. Provider business mailing address

197 N CARDINAL ST
SANTAQUIN UT
84655
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-0355
  • Fax:
Mailing address:
  • Phone: 801-472-2702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14224755-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: