Provider Demographics
NPI:1215239348
Name:PERTAB, JON LEROY (PHD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:LEROY
Last Name:PERTAB
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 SOUTH COTTONWOOD ST SUITE 810
Mailing Address - Street 2:NEUROSCIENCES INSTITUTE,
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-507-9800
Mailing Address - Fax:801-507-9800
Practice Address - Street 1:5171 SOUTH COTTONWOOD ST SUITE 810
Practice Address - Street 2:NEUROSCIENCES INSTITUTE,
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-507-9800
Practice Address - Fax:801-507-9800
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7759498-2501103G00000X, 103T00000X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth