MEDICARE: JEREMY KLEBBA MOTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	8351185-4201	UT

General Provider Information

NPI Number	:	1447826045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY KLEBBA MOTR/L

Provider Business Mailing Address
First Line	:	1571 S 850 W
Second Line	:
City	:	WOODS CROSS
State	:	UT
Zip	:	84087-1753
Country	:	US
Telephone Number	:	801-231-2102
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 N MEDICAL DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-4177
Country	:	US
Telephone Number	:	801-581-2121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	02/25/2022

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