Provider Demographics
NPI:1720329428
Name:MILLS, JAY R (DPT)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:R
Last Name:MILLS
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:PO BOX 2018
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-2018
Mailing Address - Country:US
Mailing Address - Phone:801-540-5545
Mailing Address - Fax:
Practice Address - Street 1:2325 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-557-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1423225100000X
UT8222367-2401225100000X
IDPT-4285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist