Healthcare Provider Details

I. General information

NPI: 1164040655
Provider Name (Legal Business Name): JONAH NICHOLAS HEYNEMAN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 YELLOWSTONE AVE # 1
POCATELLO ID
83201-4511
US

IV. Provider business mailing address

486 PHEASANT RIDGE DR APT B
CHUBBUCK ID
83202-1689
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-1488
  • Fax:
Mailing address:
  • Phone: 208-852-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6967
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: