Healthcare Provider Details

I. General information

NPI: 1508947367
Provider Name (Legal Business Name): ROBERT JAY SHETLIN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: R. JAY SHETLIN DC

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9184 SHOSHONE LAKE DR
WEST JORDAN UT
84088-5126
US

IV. Provider business mailing address

9184 SHOSHONE LAKE DR
WEST JORDAN UT
84088-6351
US

V. Phone/Fax

Practice location:
  • Phone: 801-867-9714
  • Fax:
Mailing address:
  • Phone: 801-867-9714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number3740151202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: