Provider Demographics
NPI:1194280271
Name:GATTUNG, JANA LEE (LIC ACUPUNCTURIST)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:LEE
Last Name:GATTUNG
Suffix:
Gender:F
Credentials:LIC ACUPUNCTURIST
Other - Prefix:
Other - First Name:JANA
Other - Middle Name:LEE
Other - Last Name:GATTUNG-NOONAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LIC ACUPUNCTURIST
Mailing Address - Street 1:88 LOIS LN
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-5326
Mailing Address - Country:US
Mailing Address - Phone:208-940-0902
Mailing Address - Fax:
Practice Address - Street 1:806 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4315
Practice Address - Country:US
Practice Address - Phone:208-940-0902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-29171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDACU-29OtherIDAHO LICENSE NUMBER