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General NPI Number Information
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NPI Number | 1144494105
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Entity Type | Organization
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Legal Business Name | JUMP START PEDIATRIC THERAPY, LLC
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Dates
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Enumeration Date | 04/21/2008
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Last Update Date | 01/30/2012
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Provider Practice Location Address
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Address Line | 411 W HAYCRAFT AVE STE B3
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City | COEUR D ALENE
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State | ID
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Zip | 83815-8105
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Country | US
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Telephone | 208-664-2468
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Fax | 208-667-6239
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Provider Business Mailing Address
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Address Line | 411 W HAYCRAFT AVE STE B3
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City | COEUR D ALENE
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State | ID
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Zip | 83815-8105
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Country | US
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Telephone | 208-664-2468
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Fax | 208-667-6239
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Authorized Official
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Title or Position | OWNER / PHYSICAL THERAPIST
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Name | MRS. ELLISON SANDERS
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Credential | PT
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Telephone | 208-664-2468
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT-2061
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License Number State | ID
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