Healthcare Provider Details

I. General information

NPI: 1235091083
Provider Name (Legal Business Name): JACOB EUGENE JOACHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14787 S ACADEMY PKWY
HERRIMAN UT
84096-2077
US

IV. Provider business mailing address

2329 W PAULINE WAY
WEST JORDAN UT
84088-7606
US

V. Phone/Fax

Practice location:
  • Phone: 844-732-5849
  • Fax:
Mailing address:
  • Phone: 801-661-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6321506-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: