Provider Demographics
NPI:1073296570
Name:CHEAL, JACKSON (PA-S)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:CHEAL
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:169 N GATEWAY DR STE 175
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9825
Mailing Address - Country:US
Mailing Address - Phone:435-565-6043
Mailing Address - Fax:435-220-2030
Practice Address - Street 1:1635 N 200 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1913
Practice Address - Country:US
Practice Address - Phone:435-565-6043
Practice Address - Fax:435-220-2030
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT13998192-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant