Provider Demographics
NPI:1679191738
Name:HERVEY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HERVEY
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 1:6112 S 1550 E STE 203
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-5010
Mailing Address - Country:US
Mailing Address - Phone:801-897-8711
Mailing Address - Fax:385-333-7202
Practice Address - Street 1:6112 S 1550 E STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5010
Practice Address - Country:US
Practice Address - Phone:801-897-8711
Practice Address - Fax:385-333-7202
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11229867-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist