Provider Demographics
NPI:1265999056
Name:ERICKSON, JASON SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5848 S FASHION BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-6175
Practice Address - Country:US
Practice Address - Phone:801-314-4188
Practice Address - Fax:801-314-4015
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11111343-1206363A00000X
WAPA60942025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1265999056Medicaid