Healthcare Provider Details

I. General information

NPI: 1528891553
Provider Name (Legal Business Name): JESSICA BIRD LMT, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 HERITAGE PARK BLVD STE 223
LAYTON UT
84041-5721
US

IV. Provider business mailing address

3098 W 525 N
WEST POINT UT
84015-7437
US

V. Phone/Fax

Practice location:
  • Phone: 480-432-6367
  • Fax:
Mailing address:
  • Phone: 480-432-6367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number11499140-4701
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11499140-4701
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number11499140-4701
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number11499140-4701
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number11499140-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: