Provider Demographics
NPI:1053784520
Name:SMITH, JENIFER REBECCA NILSON (PT)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:REBECCA NILSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENIFER
Other - Middle Name:REBECCA
Other - Last Name:NILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5648 S ADAMS AVENUE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TERRACE
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-475-0500
Mailing Address - Fax:
Practice Address - Street 1:5648 S. ADAMS AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-475-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT295029-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist