Provider Demographics
NPI:1255905048
Name:GRIFFIN, JACQUELINE (NP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 W EXCURSION LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5308
Mailing Address - Country:US
Mailing Address - Phone:208-385-7711
Mailing Address - Fax:
Practice Address - Street 1:2939 W EXCURSION LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5308
Practice Address - Country:US
Practice Address - Phone:208-385-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9552337163W00000X
FLAPRN11013719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse