Provider Demographics
NPI:1235412636
Name:BENTLEY, JENNIFER LYNN (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15132 S WALNUT GROVE DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5539
Mailing Address - Country:US
Mailing Address - Phone:801-831-5202
Mailing Address - Fax:
Practice Address - Street 1:5541 W 13400 S
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-5640
Practice Address - Country:US
Practice Address - Phone:801-871-4771
Practice Address - Fax:801-871-4771
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8064759-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist