Healthcare Provider Details

I. General information

NPI: 1972399772
Provider Name (Legal Business Name): JESSICA ANNE DAVIS TRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6246 S REDWOOD RD
SALT LAKE CTY UT
84123-6600
US

IV. Provider business mailing address

6246 S REDWOOD RD
SALT LAKE CITY UT
84123-6600
US

V. Phone/Fax

Practice location:
  • Phone: 801-969-1420
  • Fax:
Mailing address:
  • Phone: 801-969-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number14283103-4003
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: