Individual
DR. JOHN W JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1300 E CENTER ST, PROVO, UT 84606
(801) 344-4400
Mailing address
PO BOX 270, PROVO, UT 84603-0270
(801) 344-4400
(801) 344-4225
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2763461205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
870212456036
—
UT
05
—
D0978
—
UT
Enumeration date
12/12/2006
Last updated
12/05/2019
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