Provider Demographics
NPI:1346201209
Name:HUSSONG, JERRY WILLIAM (DDS MD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WILLIAM
Last Name:HUSSONG
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1221
Mailing Address - Country:US
Mailing Address - Phone:801-583-2787
Mailing Address - Fax:801-584-5141
Practice Address - Street 1:500 S CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1221
Practice Address - Country:US
Practice Address - Phone:801-583-2787
Practice Address - Fax:801-584-5141
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9291207ZH0000X, 207ZP0102X
CAG86484207ZH0000X, 207ZP0102X
UT3403921205207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200225018Medicaid
H08257Medicare UPIN
NV200225018Medicaid