Basic Information
| Provider Information | |||||||||
| NPI: | 1659433894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARVIS | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11337 VALLEY HEIGHTS CIR | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837096645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085620447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 448 S MAPLE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088599953 | ||||||||
| FaxNumber: | 2086293155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT863 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | TD450 | 01 | ID | BLUE CROSS | OTHER | 000010154466 | 01 | ID | BLUE SHIELD | OTHER |