Healthcare Provider Details

I. General information

NPI: 1417862194
Provider Name (Legal Business Name): JACOB RYAN HAMBLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 CENTER DR STE D350
PARK CITY UT
84098-6908
US

IV. Provider business mailing address

657 E ANNASTON PL APT 1
MURRAY UT
84107-5460
US

V. Phone/Fax

Practice location:
  • Phone: 435-383-2026
  • Fax: 435-994-3377
Mailing address:
  • Phone: 720-278-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14287862-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: