Provider Demographics
NPI:1922042209
Name:PREUCIL, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:PREUCIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:2550 ADDISON AVE E
Practice Address - Street 2:SUITE B
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6749
Practice Address - Country:US
Practice Address - Phone:208-814-7700
Practice Address - Fax:208-933-9301
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805473400Medicaid
IDP00460913OtherMCRR
IDG95877Medicare UPIN
ID11420461Medicare PIN