Provider Demographics
NPI:1871632646
Name:WEISHAAR, JAMIE (MPT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WEISHAAR
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 S PROGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5619
Mailing Address - Country:US
Mailing Address - Phone:208-895-0309
Mailing Address - Fax:208-895-0311
Practice Address - Street 1:745 S PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5619
Practice Address - Country:US
Practice Address - Phone:208-895-0309
Practice Address - Fax:208-895-0311
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28099225100000X
IDPT2909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28099OtherPHYSICAL THERAPY
IDPT2909OtherPHYSICAL THERAPY
COPT10765OtherPHYSICAL THERAPY