Provider Demographics
NPI:1942338496
Name:CASCADE FOOT AND ANKLE CLINIC PC
Entity Type:Organization
Organization Name:CASCADE FOOT AND ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-SOLE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-373-2499
Mailing Address - Street 1:1973 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1012
Mailing Address - Country:US
Mailing Address - Phone:801-373-2499
Mailing Address - Fax:
Practice Address - Street 1:1973 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5711
Practice Address - Country:US
Practice Address - Phone:801-373-2499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3709460501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528217084001Medicaid
UT5203910001Medicare NSC
UTU000078171Medicare PIN