Provider Demographics
NPI:1942561311
Name:KOWALLIS, JASON (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KOWALLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W 200 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2834
Mailing Address - Country:US
Mailing Address - Phone:435-722-5890
Mailing Address - Fax:
Practice Address - Street 1:165 W 200 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2834
Practice Address - Country:US
Practice Address - Phone:435-722-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8288486152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy