Healthcare Provider Details

I. General information

NPI: 1932831328
Provider Name (Legal Business Name): JACOB ISAACSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2022
Last Update Date: 06/26/2022
Certification Date: 06/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2353 N MAIN ST
SUNSET UT
84015-2454
US

IV. Provider business mailing address

481 W 500 N
CLEARFIELD UT
84015-3943
US

V. Phone/Fax

Practice location:
  • Phone: 801-825-2262
  • Fax:
Mailing address:
  • Phone: 801-513-8459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9549963-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: