Provider Demographics
NPI:1003829086
Name:JACKSON, SHELDON (PA)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 E HIGHWAY 193
Mailing Address - Street 2:SUITE G-1
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-8544
Mailing Address - Country:US
Mailing Address - Phone:801-771-1331
Mailing Address - Fax:
Practice Address - Street 1:1240 E HIGHWAY 193
Practice Address - Street 2:SUITE G-1
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-8544
Practice Address - Country:US
Practice Address - Phone:801-771-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6246293-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00424201OtherRAILROAD MEDICARE
UTQ73178Medicare UPIN