Healthcare Provider Details

I. General information

NPI: 1154185148
Provider Name (Legal Business Name): JACOB PROFFIT DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W 300 N
LOGAN UT
84321-3809
US

IV. Provider business mailing address

9195 N 6400 W
TREMONTON UT
84337-8603
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-8535
  • Fax:
Mailing address:
  • Phone: 425-512-2951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11965771-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number11965771-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: