Provider Demographics
NPI:1053505396
Name:TIBBITTS, JEREMIAH LEE (DC)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:LEE
Last Name:TIBBITTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7149 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8620
Mailing Address - Country:US
Mailing Address - Phone:425-394-3991
Mailing Address - Fax:
Practice Address - Street 1:7149 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8620
Practice Address - Country:US
Practice Address - Phone:425-394-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor