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General NPI Number Information
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NPI Number | 1992030803
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Entity Type | Individual
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Provider Name | JEFFERSON JACKSON WETHERINGTON MS, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 10/09/2009
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Last Update Date | 03/19/2020
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Provider Practice Location Address
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Address Line | 600 N ROBBINS RD STE 200
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City | BOISE
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State | ID
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Zip | 83702-4565
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Country | US
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Telephone | 616-447-9996
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Fax |
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Provider Business Mailing Address
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Address Line | 600 N ROBBINS RD STE 401
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City | BOISE
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State | ID
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Zip | 83702-4566
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Country | US
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Telephone | 208-706-9439
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2601001331
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL 2738
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 10160747
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 246Z00000X
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Taxonomy Name | Other Specialist/Technologist
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License Number | #13-0839
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License Number State | ID
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Taxonomy #5
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT468
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License Number State | ID
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