Provider Demographics
NPI:1588205959
Name:CROSSLEY, JACOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CROSSLEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13186 S CATAWBA RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6836
Mailing Address - Country:US
Mailing Address - Phone:208-252-1071
Mailing Address - Fax:
Practice Address - Street 1:1515 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4039
Practice Address - Country:US
Practice Address - Phone:208-345-7684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist