Provider Demographics
NPI:1407977903
Name:SKIDMORE, JON BULLOCK (PSYD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:BULLOCK
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:PSYD
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 336
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-0336
Mailing Address - Country:US
Mailing Address - Phone:801-426-2685
Mailing Address - Fax:801-224-4475
Practice Address - Street 1:363 E 1200 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6904
Practice Address - Country:US
Practice Address - Phone:801-426-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT266381-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical