1053778373 NPI number — MRS. JEANNA CHAY COLBORN MA, SE

Table of content: (NPI 1912975038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053778373 NPI number — MRS. JEANNA CHAY COLBORN MA, SE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLBORN
Provider First Name:
JEANNA
Provider Middle Name:
CHAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, SE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANGENWALTER
Provider Other First Name:
JEANNA
Provider Other Middle Name:
CHAY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, SE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053778373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SANCTUARY 4737 AFTON PL
Provider Second Line Business Mailing Address:
STE #A
Provider Business Mailing Address City Name:
CHUBBUCK
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-417-0623
Provider Business Mailing Address Fax Number:
208-417-0641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SANCTUARY 4737 AFTON PL
Provider Second Line Business Practice Location Address:
STE #A
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-417-0623
Provider Business Practice Location Address Fax Number:
208-417-0641
Provider Enumeration Date:
01/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  SE - 202928 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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