Provider Demographics
NPI:1134165590
Name:DEMOND, JEFFREY BOWEN (MPT, CLT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BOWEN
Last Name:DEMOND
Suffix:
Gender:M
Credentials:MPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2654 N GOLDENEYE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7803
Mailing Address - Country:US
Mailing Address - Phone:208-887-1388
Mailing Address - Fax:
Practice Address - Street 1:2321 E GALA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4881
Practice Address - Country:US
Practice Address - Phone:208-888-4321
Practice Address - Fax:208-895-8747
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010154278OtherREGENCE BLUE SHIELD ID
ID11571122OtherFIRST HEALTH CAQH
IDTD264OtherBLUE CROSS OF IDAHO
ID11571122OtherFIRST HEALTH CAQH
ID000010154278OtherREGENCE BLUE SHIELD ID