Provider Demographics
NPI:1528039377
Name:DICKERSON, JASON BRENT (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BRENT
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 S 3000 E
Mailing Address - Street 2:STE 210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6972
Mailing Address - Country:US
Mailing Address - Phone:435-615-8822
Mailing Address - Fax:435-615-8823
Practice Address - Street 1:6360 S 3000 E
Practice Address - Street 2:STE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6972
Practice Address - Country:US
Practice Address - Phone:801-265-0600
Practice Address - Fax:801-265-8600
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4830364-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012577Medicare ID - Type Unspecified
UTU86186Medicare UPIN