Healthcare Provider Details

I. General information

NPI: 1396452074
Provider Name (Legal Business Name): JESSIE TAYLOR ABBOTT MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 W UNIVERSITY BLVD
CEDAR CITY UT
84720-2415
US

IV. Provider business mailing address

364 N 1000 W APT 2
CEDAR CITY UT
84721-4199
US

V. Phone/Fax

Practice location:
  • Phone: 435-865-8355
  • Fax:
Mailing address:
  • Phone: 801-577-3357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0759
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number13093584-4810
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: