Provider Demographics
NPI:1417505355
Name:PUFNOCK, JEFFREY (LAC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:PUFNOCK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6162 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860-8837
Mailing Address - Country:US
Mailing Address - Phone:208-254-1188
Mailing Address - Fax:
Practice Address - Street 1:101 N 4TH AVE STE 101B
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1359
Practice Address - Country:US
Practice Address - Phone:208-254-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-370171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDACU-370OtherACUPUNCTURE LICENSE