Individual
JERRALYN R WASYLYSHEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
4650 HAWTHORNE RD STE 2B, CHUBBUCK, ID 83202-2376
(208) 238-3349
Mailing address
PO BOX 6032, POCATELLO, ID 83205-6032
(208) 238-3349
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT-1796
ID
Other
Enumeration date
12/01/2011
Last updated
12/01/2011
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