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General NPI Number Information
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NPI Number | 1215270053
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Entity Type | Individual
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Provider Name | CRISTA ANN JARDINE PTA
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Gender | Female
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Dates
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Enumeration Date | 03/29/2013
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Last Update Date | 03/29/2013
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Provider Practice Location Address
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Address Line | 2499 FIELDSTONE DR
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City | AMMON
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State | ID
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Zip | 83401-5854
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Country | US
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Telephone | 208-681-6677
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Fax | 208-209-8574
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Provider Business Mailing Address
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Address Line | 2499 FIELDSTONE DR
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City | AMMON
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State | ID
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Zip | 83401-5854
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Country | US
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Telephone | 208-681-6677
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Fax | 208-209-8574
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | PTA-110
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License Number State | ID
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