Provider Demographics
NPI:1861653909
Name:ANDERSON, REBECCA JO (MS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0711
Mailing Address - Country:US
Mailing Address - Phone:208-359-9570
Mailing Address - Fax:208-359-9580
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-360-8005
Practice Address - Fax:208-359-9580
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTLP-256225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist