=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871455535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY MATTEA JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2025
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 AVIATION DR STE 201
-----------------------------------------------------
City | HAILEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83333-8785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-727-8281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 W BULLION ST
-----------------------------------------------------
City | HAILEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83333-8506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1371587
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------