Provider Demographics
NPI:1992250468
Name:GREMMERT, JACOB D
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:GREMMERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7434 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2014
Mailing Address - Country:US
Mailing Address - Phone:801-456-9955
Mailing Address - Fax:
Practice Address - Street 1:7434 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2014
Practice Address - Country:US
Practice Address - Phone:801-456-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health