Provider Demographics
NPI:1194776005
Name:HOLMES, JASON EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:EDWARD
Last Name:HOLMES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1553 W 9000 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9219
Mailing Address - Country:US
Mailing Address - Phone:801-561-7300
Mailing Address - Fax:801-561-7300
Practice Address - Street 1:1553 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9219
Practice Address - Country:US
Practice Address - Phone:801-561-7300
Practice Address - Fax:801-561-7300
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114312-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT410985054103Medicaid
UT410985054103Medicaid