1346764701 NPI number — JACOB STEVEN CRAWFORD DPT, OCS

Table of content: JACOB STEVEN CRAWFORD DPT, OCS (NPI 1346764701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346764701 NPI number — JACOB STEVEN CRAWFORD DPT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD
Provider First Name:
JACOB
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT, OCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRAWFORD
Provider Other First Name:
JAKE
Provider Other Middle Name:
STEVEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1346764701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 E STATE ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-5915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-939-9594
Provider Business Mailing Address Fax Number:
208-939-9828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1673 W SHORELINE DR STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-6752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-343-4700
Provider Business Practice Location Address Fax Number:
208-343-4706
Provider Enumeration Date:
07/27/2017

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: 225100000X , with the licence number:  PT-5291 , 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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