MEDICARE: DR. JARED CRAIG JESPERSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5451902-9921	UT

General Provider Information

NPI Number	:	1134340698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JARED CRAIG JESPERSON DDS

Provider Business Mailing Address
First Line	:	1140 BRICKYARD RD
Second Line	:	#32B
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2565
Country	:	US
Telephone Number	:	801-474-9552
Fax Number	:	801-474-9558

Provider Business Practice Location Address
First Line	:	1140 BRICKYARD RD
Second Line	:	#32B
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2565
Country	:	US
Telephone Number	:	801-474-9552
Fax Number	:	801-474-9558

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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