Provider Demographics
NPI:1881072817
Name:JUMP START PEDIATRICS
Entity type:Organization
Organization Name:JUMP START PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-664-2468
Mailing Address - Street 1:411 W HAYCRAFT AVE STE D4
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 W HAYCRAFT AVE STE D4
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8104
Practice Address - Country:US
Practice Address - Phone:206-664-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1455251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage