Provider Demographics
NPI:1841879434
Name:STEPHENS, JESSE DILON (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:DILON
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:DILON
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT,DPT
Mailing Address - Street 1:12579 S CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9254
Mailing Address - Country:US
Mailing Address - Phone:801-712-6705
Mailing Address - Fax:
Practice Address - Street 1:3000 N TRIUMPH BLVD STE 310
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4999
Practice Address - Country:US
Practice Address - Phone:801-766-2088
Practice Address - Fax:385-336-2454
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11806901-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11806901-2401OtherUTAH DOPL PT LICENSE