Basic Information
| Provider Information | |||||||||
| NPI: | 1114087996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 EAST 100 NORTH | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846340759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4355282130 | ||||||||
| FaxNumber: | 4355282197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2870211205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DO972 | 05 | UT | MEDICAID | 870212456036 | 05 | UT | MEDICAID |