Healthcare Provider Details

I. General information

NPI: 1487367728
Provider Name (Legal Business Name): EDWARD WILLIAM JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

786 S LEFT HAND FORK HOBBLE CREEK CYN
SPRINGVILLE UT
84663-5916
US

IV. Provider business mailing address

786 S LEFT HAND FORK HOBBLE CREEK CYN
SPRINGVILLE UT
84663-5916
US

V. Phone/Fax

Practice location:
  • Phone: 801-489-9381
  • Fax:
Mailing address:
  • Phone: 801-489-9381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number183721-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number183721-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: