=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184748691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TREVOR JAMESON M.S., A.T.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1825 E SOUTH CAMPUS DR
-----------------------------------------------------
City | SLC
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84112-0900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-585-3861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5452 HEWS PL
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84118-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-840-5152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 6312558-4810
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------