Provider Demographics
NPI:1891129912
Name:PATTILLO, JACOB (ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PATTILLO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2722
Mailing Address - Country:US
Mailing Address - Phone:801-209-3880
Mailing Address - Fax:
Practice Address - Street 1:233 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2722
Practice Address - Country:US
Practice Address - Phone:801-209-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8385126-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer