Healthcare Provider Details

I. General information

NPI: 1053963041
Provider Name (Legal Business Name): JESSICA MEGHAN MONTGOMERY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

1043 E 300 S
SALT LAKE CITY UT
84102-2523
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2574
  • Fax: 801-585-3498
Mailing address:
  • Phone: 512-796-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10856845-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2251H1300X
TaxonomyHuman Factors Physical Therapist
License Number10856845-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: