Provider Demographics
NPI:1790359594
Name:SANSOM, JARED CLIVE (PTA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:CLIVE
Last Name:SANSOM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3352 N KINGSWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4385
Mailing Address - Country:US
Mailing Address - Phone:208-421-5991
Mailing Address - Fax:
Practice Address - Street 1:3352 N KINGSWOOD WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4385
Practice Address - Country:US
Practice Address - Phone:208-421-5991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-4725225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty