Healthcare Provider Details

I. General information

NPI: 1164512760
Provider Name (Legal Business Name): CHRISTOPHER G. JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

PO BOX 413033
SALT LAKE CITY UT
84141-3033
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-4333
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number166724-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: