Provider Demographics
NPI:1396452074
Name:ABBOTT, JESSIE TAYLOR (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:TAYLOR
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 N 1000 W APT 2
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-4199
Mailing Address - Country:US
Mailing Address - Phone:801-577-3357
Mailing Address - Fax:
Practice Address - Street 1:351 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-2415
Practice Address - Country:US
Practice Address - Phone:435-865-8355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD07592255A2300X
UT13093584-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer