Provider Demographics
NPI:1215493614
Name:ROSE, JARED ANDREW (DPT)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:ANDREW
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR STE 350
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7674
Mailing Address - Country:US
Mailing Address - Phone:801-295-3553
Mailing Address - Fax:801-295-3599
Practice Address - Street 1:121 N WASHINGTON
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:307-885-4278
Practice Address - Fax:307-885-4270
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3957225100000X
WYPT-2055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPT-2055OtherWYOMING PHYSICAL THERAPY LICENSE