Provider Demographics
NPI:1376007575
Name:MONTGOMERY, JESSE ROBERTSON (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:ROBERTSON
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 E 5900 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7254
Mailing Address - Country:US
Mailing Address - Phone:801-473-9369
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9852709-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant