Provider Demographics
NPI:1083378194
Name:GROESBECK, JAKE (LMT)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:GROESBECK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 N 100 E STE A
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1904
Mailing Address - Country:US
Mailing Address - Phone:801-897-8711
Mailing Address - Fax:385-333-7202
Practice Address - Street 1:186 N 100 E STE A
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1904
Practice Address - Country:US
Practice Address - Phone:801-897-8711
Practice Address - Fax:385-333-7202
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12250312-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty