Provider Demographics
NPI:1962418210
Name:JACKSON, BRENT D (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-743-5555
Mailing Address - Fax:
Practice Address - Street 1:700 S HIGHWAY 99
Practice Address - Street 2:#3
Practice Address - City:FILLMORE
Practice Address - State:UT
Practice Address - Zip Code:84631-5134
Practice Address - Country:US
Practice Address - Phone:435-743-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1638281205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063330Medicare PIN