Healthcare Provider Details

I. General information

NPI: 1144494105
Provider Name (Legal Business Name): JUMP START PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2008
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W HAYCRAFT AVE STE B3
COEUR D ALENE ID
83815-8105
US

IV. Provider business mailing address

411 W HAYCRAFT AVE STE B3
COEUR D ALENE ID
83815-8105
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-2468
  • Fax: 208-667-6239
Mailing address:
  • Phone: 208-664-2468
  • Fax: 208-667-6239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT-2061
License Number StateID

VIII. Authorized Official

Name: MRS. ELLISON SANDERS
Title or Position: OWNER / PHYSICAL THERAPIST
Credential: PT
Phone: 208-664-2468