MEDICARE: JACLYN LONG DPT

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	11399812-2401	UT

General Provider Information

NPI Number	:	1841849916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN LONG DPT

Provider Business Mailing Address
First Line	:	PO BOX 540640
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-0640
Country	:	US
Telephone Number	:	801-987-8600
Fax Number	:

Provider Business Practice Location Address
First Line	:	3540 S 4000 W STE 340
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-3287
Country	:	US
Telephone Number	:	801-417-5017
Fax Number	:	801-417-5016

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

Provider Enumeration Date	:	09/10/2019
Last Update Date	:	09/10/2019

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Directions to “ JACLYN LONG DPT” Practice Location

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