Provider Demographics
NPI:1710565551
Name:ROUSE, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ROUSE
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 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-289-3841
Mailing Address - Fax:
Practice Address - Street 1:606 MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDRICK
Practice Address - State:ID
Practice Address - Zip Code:83537-8353
Practice Address - Country:US
Practice Address - Phone:208-289-3841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID67523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily