Healthcare Provider Details

I. General information

NPI: 1093165599
Provider Name (Legal Business Name): JESSICA KEELY WAHL OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 N MAIN ST
BOUNTIFUL UT
84010-6136
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 16-624-9498
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283XC2000X
TaxonomyChildren's Rehabilitation Hospital
License Number9819390-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: