Healthcare Provider Details

I. General information

NPI: 1396623369
Provider Name (Legal Business Name): JEFFERY WURTS CTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7292 N CALAMONTE LN
COEUR D ALENE ID
83815-8547
US

IV. Provider business mailing address

7292 N CALAMONTE LN
COEUR D ALENE ID
83815-8547
US

V. Phone/Fax

Practice location:
  • Phone: 805-630-5555
  • Fax:
Mailing address:
  • Phone: 805-630-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: