Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VM0101X | Gynecologist - Maternal & Fetal Medicine | 185118-1205 | UT |
NPI | 1356421259 |
---|---|
Provider Name | Gilbert Marc Jackson |
First Address | Salt Lake City, UT 84158-0859 |
Second Address | Salt Lake City, UT 84132-0002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2006 |
Last Update Date | 20/10/2017 |