Healthcare Provider Details

I. General information

NPI: 1285206854
Provider Name (Legal Business Name): JACK DAVISON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

IV. Provider business mailing address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-852-4735
  • Fax:
Mailing address:
  • Phone: 801-852-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number302471-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number302471-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: