Provider Demographics
NPI:1306611587
Name:AGAPE, JENNIFER (LMT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:AGAPE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4287 HARRISON BLVD
Mailing Address - Street 2:PMB 205
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3101
Mailing Address - Country:US
Mailing Address - Phone:801-675-8574
Mailing Address - Fax:
Practice Address - Street 1:1140 36TH ST STE 285
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2064
Practice Address - Country:US
Practice Address - Phone:801-675-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7354938-4701172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist