Provider Demographics
NPI:1205179751
Name:MOSS, JACOB WAYNE (MD, JD)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:WAYNE
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2210
Mailing Address - Country:US
Mailing Address - Phone:208-313-1438
Mailing Address - Fax:
Practice Address - Street 1:283 N 1ST ST
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5109
Practice Address - Country:US
Practice Address - Phone:208-354-2302
Practice Address - Fax:208-354-8392
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GATM190208D00000X
390200000X
IDM-14547208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program