Provider Demographics
NPI:1194721704
Name:KULLAND, JERRY D (PT)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:KULLAND
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 N VERNAL AVE
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3701
Mailing Address - Country:US
Mailing Address - Phone:435-789-0022
Mailing Address - Fax:435-789-2955
Practice Address - Street 1:1180 N VERNAL AVE
Practice Address - Street 2:STE 3
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-4819
Practice Address - Country:US
Practice Address - Phone:435-789-0022
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121905-2401225100000X
CO4616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000006785Medicare ID - Type Unspecified