Basic Information
| Provider Information | |||||||||
| NPI: | 1700267168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVELLE | ||||||||
| FirstName: | JACQUELYN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 S. 500 E. | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812843 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9307924-8016 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.