Provider Demographics
NPI:1023791688
Name:HOLT, JACOB (PT, DPT, MS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HOLT
Suffix:
Gender:M
Credentials:PT, DPT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W CIVIC CENTER DR APT 322
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-1235
Mailing Address - Country:US
Mailing Address - Phone:619-246-3039
Mailing Address - Fax:
Practice Address - Street 1:5151 900 E #100
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117
Practice Address - Country:US
Practice Address - Phone:801-261-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13395764-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic