Healthcare Provider Details

I. General information

NPI: 1528039377
Provider Name (Legal Business Name): JASON BRENT DICKERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 S 3000 E STE 210
SALT LAKE CITY UT
84121-6972
US

IV. Provider business mailing address

6360 S 3000 E STE 210
SALT LAKE CITY UT
84121-6972
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-0600
  • Fax: 801-265-8600
Mailing address:
  • Phone: 435-615-8822
  • Fax: 435-615-8823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number4830364-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: