Provider Demographics
NPI:1184278913
Name:JACKSON, MATTHEW (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-393-5355
Mailing Address - Fax:801-394-4609
Practice Address - Street 1:2240 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1511
Practice Address - Country:US
Practice Address - Phone:801-393-5355
Practice Address - Fax:801-394-4609
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT126260058906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine