Provider Demographics
NPI:1801846498
Name:REPULSKI, JANA NICOLE (PT, OCS)
Entity Type:Individual
Prefix:MS
First Name:JANA
Middle Name:NICOLE
Last Name:REPULSKI
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-1328
Mailing Address - Country:US
Mailing Address - Phone:208-938-8020
Mailing Address - Fax:208-938-8016
Practice Address - Street 1:533 S RIVERSHORE LN
Practice Address - Street 2:SUITE 120
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4979
Practice Address - Country:US
Practice Address - Phone:208-938-8020
Practice Address - Fax:208-938-8016
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807415500Medicaid
ID807415500Medicaid