Provider Demographics
NPI:1255182127
Name:IPSON, JAMIE (PTA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:IPSON
Suffix:
Gender:F
Credentials:PTA
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 398
Mailing Address - Street 2:
Mailing Address - City:OAK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84649-0398
Mailing Address - Country:US
Mailing Address - Phone:435-406-6888
Mailing Address - Fax:
Practice Address - Street 1:95 WHITE SAGE AVE STE C
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624-5555
Practice Address - Country:US
Practice Address - Phone:435-864-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9809381-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant