Provider Demographics
NPI:1770097958
Name:ATHERTON, JENNESA (DPT)
Entity type:Individual
Prefix:
First Name:JENNESA
Middle Name:
Last Name:ATHERTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNESA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 E WADSWORTH PARK DR STE 230
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8096
Mailing Address - Country:US
Mailing Address - Phone:815-814-3398
Mailing Address - Fax:
Practice Address - Street 1:65 E WADSWORTH PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8096
Practice Address - Country:US
Practice Address - Phone:815-814-3398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2354225100000X
ALPTH10420225100000X
SC9333225100000X
KS11-06870225100000X
PAPT026454225100000X
WI14933-24225100000X
CA301084225100000X
FLPT38040225100000X
NY048452225100000X
IL070.026050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist