Healthcare Provider Details

I. General information

NPI: 1083270276
Provider Name (Legal Business Name): JESSICA MARIE WETSEL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 W 600 S APT 14
PROVO UT
84601-4125
US

IV. Provider business mailing address

761 W 600 S APT 14
PROVO UT
84601-4125
US

V. Phone/Fax

Practice location:
  • Phone: 540-849-6576
  • Fax:
Mailing address:
  • Phone: 540-849-6576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

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: