Healthcare Provider Details

I. General information

NPI: 1649822719
Provider Name (Legal Business Name): JESSICA REGNIER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD STE 204
BOISE ID
83706-1340
US

IV. Provider business mailing address

1060 E 2475 S
HAGERMAN ID
83332-5076
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3315
  • Fax:
Mailing address:
  • Phone: 208-731-7137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: