Provider Demographics
NPI:1023216538
Name:SOUTHARD, JENNIFER A (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5100
Mailing Address - Fax:208-302-5155
Practice Address - Street 1:6533 EMERALD STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8737
Practice Address - Country:US
Practice Address - Phone:208-302-5100
Practice Address - Fax:208-302-5155
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2000-0386207Q00000X
IDM-11245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRS2000-0386OtherTRAINING LICENSE