Healthcare Provider Details

I. General information

NPI: 1861571648
Provider Name (Legal Business Name): SCOTT MICHAEL JEROME PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N MEDICAL DR
SALT LAKE CITY UT
84113-1105
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-883-4646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number283650-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number283650-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: