Healthcare Provider Details

I. General information

NPI: 1619235736
Provider Name (Legal Business Name): JASON ALAN JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2493 S WILDCAT WAY UNIT B
WOODS CROSS UT
84010-8292
US

IV. Provider business mailing address

625 CAYIAS DR
NORTH SALT LAKE UT
84054-3161
US

V. Phone/Fax

Practice location:
  • Phone: 801-693-3020
  • Fax: 801-693-3024
Mailing address:
  • Phone: 775-505-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15746
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11431575-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: