Healthcare Provider Details

I. General information

NPI: 1124536503
Provider Name (Legal Business Name): JACOB DUANE REESOR DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3980 S 700 E STE 23
SALT LAKE CITY UT
84107-2530
US

IV. Provider business mailing address

3980 S 700 E STE 23
SALT LAKE CITY UT
84107-2530
US

V. Phone/Fax

Practice location:
  • Phone: 801-641-6571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number10668583-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: