Provider Demographics
NPI:1760555288
Name:FOOT DYNAMICS
Entity Type:Organization
Organization Name:FOOT DYNAMICS
Other - Org Name:JEFFREY T. JACOBS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:208-386-3338
Mailing Address - Street 1:1021 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5706
Mailing Address - Country:US
Mailing Address - Phone:208-386-3338
Mailing Address - Fax:208-386-3250
Practice Address - Street 1:1021 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5706
Practice Address - Country:US
Practice Address - Phone:208-386-3338
Practice Address - Fax:208-386-3250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty