Healthcare Provider Details

I. General information

NPI: 1952633133
Provider Name (Legal Business Name): JESSICA SELU MURDOCH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 E 950 S
PAYSON UT
84651-3314
US

IV. Provider business mailing address

286 E 950 S
PAYSON UT
84651-3314
US

V. Phone/Fax

Practice location:
  • Phone: 801-380-2191
  • Fax:
Mailing address:
  • Phone: 801-380-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number7562205-4810
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: