Healthcare Provider Details

I. General information

NPI: 1063039824
Provider Name (Legal Business Name): DENNIS N. JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2020
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

IV. Provider business mailing address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number13323091-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036172023
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number13323091-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number27025
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: