Provider Demographics
NPI:1073991915
Name:STEPHENS, JACK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:STEPHENS
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 1:6140 SHARON CIR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5008
Mailing Address - Country:US
Mailing Address - Phone:435-901-2735
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-387-3709
Practice Address - Fax:801-387-3725
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR74955207R00000X
UT10476493-8905207R00000X
UT10476493-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine