Provider Demographics
NPI:1457089211
Name:ALTROGGE, JARROD STEPHEN (DPT)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:STEPHEN
Last Name:ALTROGGE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 E COPPER POINT DR UNIT 0-103
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7847
Mailing Address - Country:US
Mailing Address - Phone:406-839-6988
Mailing Address - Fax:208-288-2784
Practice Address - Street 1:1626 S WELLS AVE STE 105
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4528
Practice Address - Country:US
Practice Address - Phone:208-789-0200
Practice Address - Fax:208-288-2784
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IDPT-8292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-8292OtherIDAHO DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSES