Provider Demographics
NPI:1417998162
Name:ALLRED, JASON D (DPT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
Last Name:ALLRED
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 1:1588 W CAYUSE CREEK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4795
Mailing Address - Country:US
Mailing Address - Phone:208-515-7575
Mailing Address - Fax:208-515-7578
Practice Address - Street 1:1588 W CAYUSE CREEK DR
Practice Address - Street 2:STE 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4795
Practice Address - Country:US
Practice Address - Phone:208-515-7575
Practice Address - Fax:208-515-7578
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807301900Medicaid
IDTD132OtherBLUE CROSS OF ID
ID000010151111OtherBLUE SHIELD OF ID
ID807301900Medicaid