Provider Demographics
NPI:1558593285
Name:JESPERSON, JUSTIN DAVID (DC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:JESPERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16730 N MARKETPLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-7909
Mailing Address - Country:US
Mailing Address - Phone:208-466-4600
Mailing Address - Fax:
Practice Address - Street 1:16730 N MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7909
Practice Address - Country:US
Practice Address - Phone:208-466-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1910111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor