Provider Demographics
NPI:1730747411
Name:MATERN, JAKE ROGER (DPT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ROGER
Last Name:MATERN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR STE 350
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7674
Mailing Address - Country:US
Mailing Address - Phone:801-295-3553
Mailing Address - Fax:801-295-3599
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR STE 350
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7674
Practice Address - Country:US
Practice Address - Phone:801-295-3553
Practice Address - Fax:801-295-3599
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist