Provider Demographics
NPI:1275926149
Name:JACKSON, CALEB R (FNP)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5171 S COTTONWOOD ST STE 950
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5713
Mailing Address - Country:US
Mailing Address - Phone:801-507-9542
Mailing Address - Fax:801-507-9550
Practice Address - Street 1:1220 E 3900 S STE 4E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1343
Practice Address - Country:US
Practice Address - Phone:801-261-8507
Practice Address - Fax:801-261-8511
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT347183-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily