Provider Demographics
NPI:1144494105
Name:JUMP START PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:JUMP START PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-664-2468
Mailing Address - Street 1:411 W HAYCRAFT AVE
Mailing Address - Street 2:STE B3
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8105
Mailing Address - Country:US
Mailing Address - Phone:208-664-2468
Mailing Address - Fax:208-667-6239
Practice Address - Street 1:411 W HAYCRAFT AVE
Practice Address - Street 2:STE B3
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8105
Practice Address - Country:US
Practice Address - Phone:208-664-2468
Practice Address - Fax:208-667-6239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2061261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807908300Medicaid
000010164610OtherREGENCE BLUE SHIELD
TD687OtherBLUE CROSS OF IDAHO
000010164610OtherREGENCE BLUE SHIELD