Healthcare Provider Details

I. General information

NPI: 1417892225
Provider Name (Legal Business Name): PROACTIVE PHYSICAL TRERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 S FASHION BLVD STE 120
MURRAY UT
84107-7383
US

IV. Provider business mailing address

6095 S FASHION BLVD STE 120
MURRAY UT
84107-7383
US

V. Phone/Fax

Practice location:
  • Phone: 801-210-0127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID JACOBSON
Title or Position: COO
Credential:
Phone: 503-510-2536