Individual
JASON LEE BLACKHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4403 HARRISON BLVD, SUITE 2400, OGDEN, UT 84403-3271
(801) 387-2750
(801) 387-2755
Mailing address
PO BOX 27128, SALT LAKE CITY, UT 84127-0128
(801) 387-2750
(801) 387-2755
Taxonomy
Speciality
Code
Description
License number
State
207RS0010X
Sports Medicine (Internal Medicine) Physician
Primary
7216493-1205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00685134
MEDICARE RAILROAD
UT
Enumeration date
06/16/2007
Last updated
09/22/2011
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