Healthcare Provider Details

I. General information

NPI: 1023353711
Provider Name (Legal Business Name): JESSICA DERRICK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 W 12600 S STE 1
RIVERTON UT
84065-7273
US

IV. Provider business mailing address

12508 S SHADE LN
RIVERTON UT
84065-1678
US

V. Phone/Fax

Practice location:
  • Phone: 801-810-0569
  • Fax:
Mailing address:
  • Phone: 801-574-7692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: