MEDICARE: JILL WENNESON MSPT

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	225100000X	Physical Therapist	4803045-2401	UT

General Provider Information

NPI Number	:	1639426000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL WENNESON MSPT

Provider Business Mailing Address
First Line	:	1201 E 4500 S
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4124
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 E 4500 S
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4124
Country	:	US
Telephone Number	:	801-261-3664
Fax Number	:

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

Provider Enumeration Date	:	08/05/2012
Last Update Date	:	05/08/2013

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