Healthcare Provider Details

I. General information

NPI: 1194910943
Provider Name (Legal Business Name): JEFFRY WILLIAM SPECKMAN ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD SUITE 2440
OGDEN UT
84403-3271
US

IV. Provider business mailing address

4403 HARRISON BLVD SUITE 2440
OGDEN UT
84403-3271
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-2775
  • Fax: 801-387-2780
Mailing address:
  • Phone: 801-387-2775
  • Fax: 801-387-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number284667-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: