Provider Demographics
NPI:1376945162
Name:WEBB, JEFF DEAN
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:DEAN
Last Name:WEBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:DEAN
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:412 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5424
Mailing Address - Country:US
Mailing Address - Phone:208-250-6741
Mailing Address - Fax:208-466-5226
Practice Address - Street 1:412 22ND AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5424
Practice Address - Country:US
Practice Address - Phone:208-250-6741
Practice Address - Fax:208-466-5226
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-346172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker