Provider Demographics
NPI:1215270053
Name:JARDINE, CRISTA ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:CRISTA
Middle Name:ANN
Last Name:JARDINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2499 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5854
Mailing Address - Country:US
Mailing Address - Phone:208-681-6677
Mailing Address - Fax:208-209-8574
Practice Address - Street 1:2499 FIELDSTONE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83401-5854
Practice Address - Country:US
Practice Address - Phone:208-681-6677
Practice Address - Fax:208-209-8574
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-110171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor