Basic Information
| Provider Information | |||||||||
| NPI: | 1205492543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MECKLENBURG | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | JOLLEY | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1443 W 800 N STE 103 | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840572878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016554950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 545 W 465 N STE 100 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843328004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357536606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2019 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-85497 | UT | Y |
No ID Information.