Provider Demographics
NPI:1417596628
Name:JENKINS, JEREMY JOHN (DPT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JOHN
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FLANDRO DR STE 190
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4940
Mailing Address - Country:US
Mailing Address - Phone:208-233-2248
Mailing Address - Fax:
Practice Address - Street 1:1800 FLANDRO DR STE 190
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4940
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:208-233-0219
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist