Provider Demographics
NPI:1710479001
Name:FOOTE, JASON (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:FOOTE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E TABERNACLE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7124
Mailing Address - Country:US
Mailing Address - Phone:435-673-3558
Mailing Address - Fax:
Practice Address - Street 1:1689 NONCONNAH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2111
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11277045-9934152W00000X
TN3443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist