Provider Demographics
NPI:1659979516
Name:GARDNER, JENNIFER ANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6145
Mailing Address - Country:US
Mailing Address - Phone:208-420-8387
Mailing Address - Fax:
Practice Address - Street 1:1385 PARK VIEW DR STE 101
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4390
Practice Address - Country:US
Practice Address - Phone:208-944-0497
Practice Address - Fax:208-944-0506
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID65975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily