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NPI Code Detail

MEDICARE: JILLYN JACKSON PTA

MEDICARE: JILLYN JACKSON PTA
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
1225200000XPhysical Therapy Assistant284914-2402UT

General Provider Information

NPI Number : 1689107542
Entity Type Code : Individual
Provider Name (Legal Business Name) : JILLYN JACKSON PTA
Provider Business Mailing Address
First Line : 1256 E 1300 S
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84105-1949
Country : US
Telephone Number : 801-641-2494
Fax Number :
Provider Business Practice Location Address
First Line : 1256 E 1300 S
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84105-1949
Country : US
Telephone Number : 801-641-2494
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/07/2017
Last Update Date : 04/07/2017

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