Provider Demographics
NPI:1083815757
Name:YATES, JEREMIAH KIRTLAND (DPT)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:KIRTLAND
Last Name:YATES
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 1:531 CAYUSE CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341
Mailing Address - Country:US
Mailing Address - Phone:208-736-1853
Mailing Address - Fax:
Practice Address - Street 1:241 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1103
Practice Address - Country:US
Practice Address - Phone:208-934-4433
Practice Address - Fax:208-934-4639
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist