Provider Demographics
NPI:1518509223
Name:MANSELL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MANSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 NAUTICAL DR
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8175
Mailing Address - Country:US
Mailing Address - Phone:801-870-0274
Mailing Address - Fax:
Practice Address - Street 1:4643 S 4000 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-6233
Practice Address - Country:US
Practice Address - Phone:801-968-1896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer