Provider Demographics
NPI:1427772664
Name:KOONTZ, JESSICA MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 E 1700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2716
Mailing Address - Country:US
Mailing Address - Phone:240-577-8031
Mailing Address - Fax:
Practice Address - Street 1:5770 S 250 E STE G50
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6165
Practice Address - Country:US
Practice Address - Phone:801-314-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12841436-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist