Provider Demographics
NPI:1497197891
Name:ANDERSON, JEFFREY C (NP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 SUMMERS DR STE B
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5335
Mailing Address - Country:US
Mailing Address - Phone:208-607-9816
Mailing Address - Fax:208-549-7883
Practice Address - Street 1:1069 SUMMERS DR STE B
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5335
Practice Address - Country:US
Practice Address - Phone:208-607-9816
Practice Address - Fax:208-549-7883
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1314A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP-1314AOtherSTATE LICENSE