Provider Demographics
NPI:1992030803
Name:WETHERINGTON, JEFFERSON JACKSON (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:JACKSON
Last Name:WETHERINGTON
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N ROBBINS RD STE 401
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4566
Mailing Address - Country:US
Mailing Address - Phone:208-706-9439
Mailing Address - Fax:
Practice Address - Street 1:600 N ROBBINS RD STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:616-447-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010013312255A2300X
FLAL 27382255A2300X
OR101607472255A2300X
ID#13-0839246Z00000X
IDAT4682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other