Provider Demographics
NPI:1811586001
Name:ROBINSON, JACKIE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:MARIE
Other - Last Name:DUPUIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:615 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRAIGMONT
Mailing Address - State:ID
Mailing Address - Zip Code:83523-5099
Mailing Address - Country:US
Mailing Address - Phone:208-717-7275
Mailing Address - Fax:
Practice Address - Street 1:615 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CRAIGMONT
Practice Address - State:ID
Practice Address - Zip Code:83523-5099
Practice Address - Country:US
Practice Address - Phone:208-717-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAN36113542363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner