Active NPI
Jason Detwiler
- Physical Therapy Assistant
- Boise, ID
National Provider Identifier
1275197667
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 40QB00360700
- Practice address
- 2411 S Essex Way
Boise, ID 83709-2304 - Phone
- (208) 353-0976
- NPI assigned
- May 1, 2019
- Last updated
- May 1, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 40QB00360700 | NJ | Primary |
Addresses
Primary practice location
2411 S Essex Way
Boise, ID 83709-2304
Mailing address
2411 S Essex Way
Boise, ID 83709-2304
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 40QB00360700 | NJ | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1556668800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1556668800000",
"number": "1275197667",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2411 S ESSEX WAY",
"city": "BOISE",
"state": "ID",
"postal_code": "837092304"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2411 S ESSEX WAY",
"city": "BOISE",
"state": "ID",
"postal_code": "837092304",
"telephone_number": "208-353-0976"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DETWILER",
"first_name": "JASON",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2019-05-01",
"last_updated": "2019-05-01",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "NJ",
"license": "40QB00360700",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.