Provider Demographics
NPI:1598357436
Name:JACK, ALYSSA MAY (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MAY
Last Name:JACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 E MENAN LORENZO HWY
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5169
Mailing Address - Country:US
Mailing Address - Phone:208-847-5762
Mailing Address - Fax:
Practice Address - Street 1:1350 PARKWAY DR STE 2
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1657
Practice Address - Country:US
Practice Address - Phone:208-782-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant