Healthcare Provider Details

I. General information

NPI: 1215637111
Provider Name (Legal Business Name): TYSON JESSOP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 S 3000 E
ST GEORGE UT
84790-1823
US

IV. Provider business mailing address

826 S 3000 E
ST GEORGE UT
84790-1823
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-0511
  • Fax:
Mailing address:
  • Phone: 435-215-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14212397
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: