Provider Demographics
NPI:1861622078
Name:MAYO, JEREMY A (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:MAYO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 E FRANKLIN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9024
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-461-4510
Practice Address - Street 1:5520 N EAGLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2700
Practice Address - Country:US
Practice Address - Phone:208-938-5255
Practice Address - Fax:208-938-5545
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT2557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist