Provider Demographics
NPI:1467914036
Name:NEWMAN, JESSE DALE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DALE
Last Name:NEWMAN
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 1:5909 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3039
Mailing Address - Country:US
Mailing Address - Phone:208-343-7700
Mailing Address - Fax:208-331-2591
Practice Address - Street 1:5909 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3039
Practice Address - Country:US
Practice Address - Phone:208-343-7700
Practice Address - Fax:208-331-2591
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-5990225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPTA-5990OtherPHYSICAL THERAPIST ASSISTANT