Provider Demographics
NPI:1639108566
Name:PRESTON, JARED M (DC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:M
Last Name:PRESTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:BUILDING C SUITE 222
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-747-0770
Mailing Address - Fax:
Practice Address - Street 1:1121 E 3900 S
Practice Address - Street 2:BUILDING C SUITE 222
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1214
Practice Address - Country:US
Practice Address - Phone:801-747-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369441-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT900703657OtherTAX ID NUMBER
UT005758401Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER