Provider Demographics
NPI:1083620553
Name:HOPSTAD, JERRET K (MPT)
Entity Type:Individual
Prefix:MR
First Name:JERRET
Middle Name:K
Last Name:HOPSTAD
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 W SHORELINE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-343-4700
Mailing Address - Fax:208-343-4706
Practice Address - Street 1:1673 W SHORELINE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-343-4700
Practice Address - Fax:208-343-4706
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT1315OtherSTATE LIC
PT1315OtherSTATE LIC