Provider Demographics
NPI:1760837066
Name:PETERSON, JASON TRENT (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:TRENT
Last Name:PETERSON
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 1:7732 N RED OAK RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4303
Mailing Address - Country:US
Mailing Address - Phone:801-644-3046
Mailing Address - Fax:
Practice Address - Street 1:4408 E PONY EXPRESS PKWY STE A
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5564
Practice Address - Country:US
Practice Address - Phone:801-789-3937
Practice Address - Fax:801-228-2420
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10382337-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist