=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548953631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN PATRICK SPROUSE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2023
-----------------------------------------------------
Last Update Date | 06/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 S HIGHWAY 165
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84332-9512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-755-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1007 E 450 N
-----------------------------------------------------
City | HEBER CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84032-3089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-671-7854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 13286986-2401
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------