Provider Demographics
NPI:1346367984
Name:WHITESELL, JACKIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:J
Last Name:WHITESELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-2800
Practice Address - Country:US
Practice Address - Phone:208-367-2800
Practice Address - Fax:208-367-7111
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-110222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology