Provider Demographics
NPI:1417356445
Name:MARKETTI, JASON (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MARKETTI
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:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0273
Mailing Address - Country:US
Mailing Address - Phone:208-745-3231
Mailing Address - Fax:
Practice Address - Street 1:2870 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4720
Practice Address - Country:US
Practice Address - Phone:208-746-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2122225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant