Provider Demographics
NPI:1619235736
Name:JOHNSON, JASON ALAN (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CAYIAS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3161
Mailing Address - Country:US
Mailing Address - Phone:775-505-7111
Mailing Address - Fax:
Practice Address - Street 1:2493 S WILDCAT WAY UNIT B
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-8292
Practice Address - Country:US
Practice Address - Phone:801-693-3020
Practice Address - Fax:801-693-3024
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15746207Q00000X
UT11431575-1205207Q00000X
TXQ2567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11431575-1205OtherUT LICENSE
NV15746OtherMD LICENSE NUMBER
NV12790436OtherCAQH