Active NPI
Robert T Jackson, MD
- Orthopaedic Surgery Physician
- Provo, UT
National Provider Identifier
1407959695
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Orthopaedic Surgery Physician
- License
- 158297-1205
- Practice address
- 1055 N 500 W
Suite 121
Provo, UT 84604-3305 - Phone
- (801) 373-7350
- Fax
- (801) 812-5401
- NPI assigned
- Sep 6, 2006
- Last updated
- Nov 2, 2018
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthopaedic Surgery Physician | 207X00000X | 158297-1205 | UT | Primary |
Addresses
Primary practice location
1055 N 500 W
Suite 121
Provo, UT 84604-3305
Mailing address
1055 N 500 W
Credentialing Department
Provo, UT 84604-3305
Phone (801) 354-8225
Other identifiers 8
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 107006624103 | Other | UT | IHC |
| 200045123 | Other | UT | PALMETTO |
| 68074 | Other | UT | PEHP |
| 09-00414 | Other | UT | UNITED HEALTHCARE |
| 35879 | Other | UT | DMBA |
| 870281028RTJ | Other | UT | EMIA |
| 870281028000 | Medicaid | UT | |
| QM0000056631 | Other | UT | ALTIUS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 158297-1205 | UT | MD | Orthopaedic Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1157500800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1541116800000",
"number": "1407959695",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1055 N 500 W",
"address_2": "CREDENTIALING DEPARTMENT",
"city": "PROVO",
"state": "UT",
"postal_code": "846043305",
"telephone_number": "801-354-8225",
"fax_number": "801-418-0941"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1055 N 500 W",
"address_2": "SUITE 121",
"city": "PROVO",
"state": "UT",
"postal_code": "846043305",
"telephone_number": "801-373-7350",
"fax_number": "801-812-5401"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "ROBERT",
"middle_name": "T",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-09-06",
"last_updated": "2018-11-02",
"status": "A"
},
"taxonomies": [
{
"code": "207X00000X",
"taxonomy_group": "",
"desc": "Orthopaedic Surgery",
"state": "UT",
"license": "158297-1205",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "IHC",
"identifier": "107006624103",
"state": "UT"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PALMETTO",
"identifier": "200045123",
"state": "UT"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PEHP",
"identifier": "68074",
"state": "UT"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED HEALTHCARE",
"identifier": "09-00414",
"state": "UT"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DMBA",
"identifier": "35879",
"state": "UT"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "EMIA",
"identifier": "870281028RTJ",
"state": "UT"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "870281028000",
"state": "UT"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ALTIUS",
"identifier": "QM0000056631",
"state": "UT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Provo, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.