Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | 7702809-4201 | UT |
NPI | 1386120624 |
---|---|
Provider Name | Mr. Keith Jewson |
First Address | Highland, UT 84003-5630 |
Second Address | Provo, UT 84604-3380 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2018 |
Last Update Date | 18/07/2018 |