Healthcare Provider Details

I. General information

NPI: 1679853501
Provider Name (Legal Business Name): BRENDA KAY JERALD DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA KAY MITCHELL DPT

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200 STE 326
PONDERAY ID
83852-5042
US

IV. Provider business mailing address

1917 N LAKEWOOD DR
COEUR D ALENE ID
83814-2634
US

V. Phone/Fax

Practice location:
  • Phone: 208-205-9559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2889
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: