Provider Demographics
NPI:1598237893
Name:HUTTON, JOHN RUSSELL JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:HUTTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 S MILLSTREAM CT
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-4838
Mailing Address - Country:US
Mailing Address - Phone:209-604-8993
Mailing Address - Fax:
Practice Address - Street 1:1461 S MILLSTREAM CT
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-4838
Practice Address - Country:US
Practice Address - Phone:209-604-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1948225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist