Provider Demographics
NPI:1366776452
Name:JAKSETIC, MATTHEW THOMAS (ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:JAKSETIC
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2561
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-2561
Mailing Address - Country:US
Mailing Address - Phone:906-282-4876
Mailing Address - Fax:
Practice Address - Street 1:1450 AVIATION DR
Practice Address - Street 2:201
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8785
Practice Address - Country:US
Practice Address - Phone:208-727-8281
Practice Address - Fax:208-727-8285
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-3642255A2300X
WI9590392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer