Provider Demographics
NPI:1205320645
Name:MCCORRISTIN, JEREMY CHRISTOPHER (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:CHRISTOPHER
Last Name:MCCORRISTIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 N CANTERBURY CT
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-7003
Mailing Address - Country:US
Mailing Address - Phone:801-400-9747
Mailing Address - Fax:
Practice Address - Street 1:4782 S HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5444
Practice Address - Country:US
Practice Address - Phone:801-277-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7958137-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist