Provider Demographics
NPI:1245389790
Name:WELKER, JEFFREY THOMAS (DC,CCSP)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:THOMAS
Last Name:WELKER
Suffix:
Gender:M
Credentials:DC,CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4725
Mailing Address - Country:US
Mailing Address - Phone:208-343-2584
Mailing Address - Fax:
Practice Address - Street 1:301 N 27TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4725
Practice Address - Country:US
Practice Address - Phone:208-343-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC-520111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC-520-4OtherBLUE CROSS OF IDAHO
ID000010007866OtherREGENCE BLUE SHIELD
IDT44503Medicare UPIN