Provider Demographics
NPI:1972687606
Name:KINGSOLVER, JEFFERY (PT)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:KINGSOLVER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:1067 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-226-0599
Practice Address - Fax:801-226-3145
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3379892401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059790Medicare PIN