Provider Demographics
NPI:1124089974
Name:MANION, JEFFREY DWAIN (MPT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DWAIN
Last Name:MANION
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 SANDY GLEN LN
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-3333
Mailing Address - Country:US
Mailing Address - Phone:402-290-4584
Mailing Address - Fax:
Practice Address - Street 1:933 SANDY GLEN LN
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-3333
Practice Address - Country:US
Practice Address - Phone:402-290-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA586685Medicaid
NE6536OtherBCBS
IA586685Medicaid
Q27285Medicare UPIN