Provider Demographics
NPI:1558143057
Name:ELIZARRARAS, JITKA MICHAELA
Entity Type:Individual
Prefix:
First Name:JITKA
Middle Name:MICHAELA
Last Name:ELIZARRARAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10064 W DEEP CANYON DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5322
Mailing Address - Country:US
Mailing Address - Phone:208-340-5425
Mailing Address - Fax:
Practice Address - Street 1:3402 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6932
Practice Address - Country:US
Practice Address - Phone:208-455-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist