Provider Demographics
NPI:1467130138
Name:MALAN, JESSE MOFFAT (LMT, MMP)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:MOFFAT
Last Name:MALAN
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N DIXIE DR UNIT 86
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-6189
Mailing Address - Country:US
Mailing Address - Phone:435-630-3452
Mailing Address - Fax:
Practice Address - Street 1:169 W 2710 SOUTH CIR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7201
Practice Address - Country:US
Practice Address - Phone:435-609-9617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7907321-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist