Healthcare Provider Details

I. General information

NPI: 1548247240
Provider Name (Legal Business Name): JENNIFER H CHANLEY P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER CALVIN CALVIN P.T.

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 W COULTER AVE
POWELL WY
82435
US

IV. Provider business mailing address

185 EVERGREEN DR
BOISE ID
83716-3023
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-9262
  • Fax:
Mailing address:
  • Phone: 208-891-1440
  • Fax: 208-442-2358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT - 2032
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01608
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1779
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: