Provider Demographics
NPI:1609951854
Name:SCOTT, JARED STEPHAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:STEPHAN
Last Name:SCOTT
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 1:856 NEWGATE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4768
Mailing Address - Country:US
Mailing Address - Phone:208-523-1750
Mailing Address - Fax:
Practice Address - Street 1:2060 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6490
Practice Address - Country:US
Practice Address - Phone:208-522-4274
Practice Address - Fax:208-522-4274
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1115111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1675694Medicare ID - Type Unspecified