Provider Demographics
NPI:1326105206
Name:TURNIPSEED-AYMON, JACKIE J (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:J
Last Name:TURNIPSEED-AYMON
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-634-1776
Mailing Address - Fax:208-634-3873
Practice Address - Street 1:1000 STATE ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3704
Practice Address - Country:US
Practice Address - Phone:208-634-1776
Practice Address - Fax:208-634-3873
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010155539OtherBLUE CROSS OF IDAHO
ID20001695Medicare PIN