Provider Demographics
NPI:1851011019
Name:FASTH, JAMILYN MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JAMILYN
Middle Name:MARIE
Last Name:FASTH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3369 S HOLDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5395
Mailing Address - Country:US
Mailing Address - Phone:208-559-4791
Mailing Address - Fax:
Practice Address - Street 1:4424 E FLAMINGO AVE STE 120
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9291
Practice Address - Country:US
Practice Address - Phone:208-205-0450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist