Provider Demographics
NPI:1154665719
Name:HANSEN, JEREMY (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 N DISCOVERY WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1556
Mailing Address - Country:US
Mailing Address - Phone:208-378-0256
Mailing Address - Fax:208-378-0269
Practice Address - Street 1:5959 N DISCOVERY WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1556
Practice Address - Country:US
Practice Address - Phone:208-378-0256
Practice Address - Fax:208-378-0269
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-341225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant