Basic Information
| Provider Information | |||||||||
| NPI: | 1639245939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIDESTER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4105 E 525 N | ||||||||
| Address2: | |||||||||
| City: | RIGBY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834425214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087055222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 36 PROFESSIONAL PLZ STE 110 | ||||||||
| Address2: | |||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834402049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083599570 | ||||||||
| FaxNumber: | 2083599580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT-756 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.