Provider Demographics
NPI:1083798748
Name:CARTER, JENNIFER MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:CARTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:451 BISHOP FEDERAL LANE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:801-493-8814
Practice Address - Fax:801-468-6843
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56015892401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5729Medicaid