Provider Demographics
NPI:1558391169
Name:SMITH, JASON LARRY (DC, MS, DACNB)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LARRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC, MS, DACNB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MEDICAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8928
Mailing Address - Country:US
Mailing Address - Phone:801-292-4400
Mailing Address - Fax:844-308-6615
Practice Address - Street 1:520 MEDICAL DR STE 200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8928
Practice Address - Country:US
Practice Address - Phone:801-292-4400
Practice Address - Fax:844-308-6615
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369867-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT350055669OtherRAILROAD MEDICARE NUMBER
UT000056239Medicare ID - Type UnspecifiedMEDICARE ID NUMBER