Provider Demographics
NPI:1417494022
Name:KOMPERUD, JACQUELYN (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:KOMPERUD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3858 N GARDEN CENTER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5008
Mailing Address - Country:US
Mailing Address - Phone:208-336-0017
Mailing Address - Fax:
Practice Address - Street 1:3858 N GARDEN CENTER WAY STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5008
Practice Address - Country:US
Practice Address - Phone:208-336-0017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2518225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist