Provider Demographics
NPI:1245793157
Name:LANDRY, JENNIFER M (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:GRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3399 E LOUISE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3399 E LOUISE DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5212
Practice Address - Country:US
Practice Address - Phone:208-288-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant