Provider Demographics
NPI:1063039204
Name:EISELE, JADELYN TAYLOR
Entity Type:Individual
Prefix:
First Name:JADELYN
Middle Name:TAYLOR
Last Name:EISELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 RAILROAD ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 RAILROAD ST APT 4
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2381
Practice Address - Country:US
Practice Address - Phone:208-392-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer