Provider Demographics
NPI:1891081790
Name:JAUSORO, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:JAUSORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2117
Mailing Address - Country:US
Mailing Address - Phone:208-587-3365
Mailing Address - Fax:208-587-1545
Practice Address - Street 1:528 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2117
Practice Address - Country:US
Practice Address - Phone:208-587-3365
Practice Address - Fax:208-587-1545
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist