Provider Demographics
NPI:1396757241
Name:SPACKMAN, JARED P (PA-C)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:P
Last Name:SPACKMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8822 SOUTH REDWOOD ROAD
Mailing Address - Street 2:C-211
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8811
Mailing Address - Country:US
Mailing Address - Phone:801-563-1975
Mailing Address - Fax:801-563-1984
Practice Address - Street 1:8822 SOUTH REDWOOD ROAD
Practice Address - Street 2:C-211
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8811
Practice Address - Country:US
Practice Address - Phone:801-563-1975
Practice Address - Fax:801-563-1984
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4808078-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012414Medicare ID - Type Unspecified