Provider Demographics
NPI:1609032267
Name:CAMP HIPPO PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:CAMP HIPPO PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:KRIS
Authorized Official - Last Name:JAQUES
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:208-782-2267
Mailing Address - Street 1:7 N 600 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5533
Mailing Address - Country:US
Mailing Address - Phone:208-782-2267
Mailing Address - Fax:
Practice Address - Street 1:7 N 600 W
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5533
Practice Address - Country:US
Practice Address - Phone:208-782-2267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA 2406225100000X
IDOT 232225X00000X
ID12125357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty