1225278112 NPI number — MRS. JEANNETTE ELISE WILCOX CMT

Table of content: MRS. JEANNETTE ELISE WILCOX CMT (NPI 1225278112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225278112 NPI number — MRS. JEANNETTE ELISE WILCOX CMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILCOX
Provider First Name:
JEANNETTE
Provider Middle Name:
ELISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225278112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1602 PINE ST APT 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDPOINT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83864-5062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-610-4001
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30410 HIGHWAY 200 UNIT 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-3211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2009

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: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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