Provider Demographics
NPI:1225597305
Name:JACKSON, LYLE JEREMY (CRNA)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:JEREMY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 BARNEY DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3542
Mailing Address - Country:US
Mailing Address - Phone:801-319-9345
Mailing Address - Fax:
Practice Address - Street 1:2325 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-557-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62439163WX0800X
VA125895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WX0800XNursing Service ProvidersRegistered NurseOrthopedicGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered