Healthcare Provider Details

I. General information

NPI: 1962952911
Provider Name (Legal Business Name): JESSIE SMITH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 S GREEN ST
SALT LAKE CITY UT
84102-3512
US

IV. Provider business mailing address

810 S GREEN ST
SALT LAKE CITY UT
84102-3512
US

V. Phone/Fax

Practice location:
  • Phone: 801-608-3872
  • Fax:
Mailing address:
  • Phone: 801-608-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10070161-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: