Healthcare Provider Details

I. General information

NPI: 1568337137
Provider Name (Legal Business Name): JARED RANDALL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 S BLUFF ST BSMT
ST GEORGE UT
84770-5245
US

IV. Provider business mailing address

325 S 200 E APT 2
ST GEORGE UT
84770-3649
US

V. Phone/Fax

Practice location:
  • Phone: 435-674-9999
  • Fax:
Mailing address:
  • Phone: 435-674-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberF22-101891
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberF23-108644
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: