Provider Demographics
NPI:1447826045
Name:KLEBBA, JEREMY (MOTR/L)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:KLEBBA
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 S 850 W
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-1753
Mailing Address - Country:US
Mailing Address - Phone:801-231-2102
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-4177
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8351185-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist