Provider Demographics
NPI:1528587268
Name:GERE, JACOB CARLTON (PNP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CARLTON
Last Name:GERE
Suffix:
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6273
Mailing Address - Country:US
Mailing Address - Phone:208-381-7370
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST STE 300
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6269
Practice Address - Country:US
Practice Address - Phone:208-381-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner