Provider Demographics
NPI:1588664759
Name:CLEGG, JARED T (DPM)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:T
Last Name:CLEGG
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 1:2561 S 1560 W
Mailing Address - Street 2:STE B
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2361
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:1973 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1012
Practice Address - Country:US
Practice Address - Phone:801-373-2499
Practice Address - Fax:801-373-5200
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-02-10
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
UT370946-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$001Medicaid
UT5203910001Medicare NSC
UTU74600Medicare UPIN
UT000012631Medicare PIN