Provider Demographics
NPI:1083236301
Name:JACOB EGBERT LLC
Entity Type:Organization
Organization Name:JACOB EGBERT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:R
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-938-8657
Mailing Address - Street 1:274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:
Practice Address - Street 1:8074 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-0743
Practice Address - Country:US
Practice Address - Phone:801-561-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty