Provider Demographics
NPI:1497311369
Name:DEERE, JACKSON WALTER (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:WALTER
Last Name:DEERE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 N 400 E STE 301
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1892
Mailing Address - Country:US
Mailing Address - Phone:435-753-7880
Mailing Address - Fax:435-753-5845
Practice Address - Street 1:2245 N 400 E STE 301
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1892
Practice Address - Country:US
Practice Address - Phone:435-753-7880
Practice Address - Fax:435-753-5845
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13768482-1205207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology