Provider Demographics
NPI:1871667451
Name:BANGS, JENNIFER M (OTD OTR L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BANGS
Suffix:
Gender:F
Credentials:OTD OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 400 E
Mailing Address - Street 2:MOUNTAIN LAND REHABILITATION
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4933
Mailing Address - Country:US
Mailing Address - Phone:801-397-8154
Mailing Address - Fax:801-397-8051
Practice Address - Street 1:401 S 400 E
Practice Address - Street 2:MOUNTAIN LAND REHABILITATION
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4933
Practice Address - Country:US
Practice Address - Phone:801-397-8154
Practice Address - Fax:801-397-8051
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5927273-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5312Medicaid