Provider Demographics
NPI:1164851168
Name:ZIMMERMAN, JESSIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:MARIE
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 S VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3453
Mailing Address - Country:US
Mailing Address - Phone:208-433-1114
Mailing Address - Fax:
Practice Address - Street 1:1906 S VISTA AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3453
Practice Address - Country:US
Practice Address - Phone:208-433-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1118363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808150000Medicaid
ID1992808893Medicare UPIN