Provider Demographics
NPI:1720450067
Name:ANTON, JACQUELYNE RENEE (NBC-HWC AND MS)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYNE
Middle Name:RENEE
Last Name:ANTON
Suffix:
Gender:F
Credentials:NBC-HWC AND MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 E WILDHORSE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7593
Mailing Address - Country:US
Mailing Address - Phone:704-608-1568
Mailing Address - Fax:
Practice Address - Street 1:4100 E WILDHORSE LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7593
Practice Address - Country:US
Practice Address - Phone:704-608-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSG-055247200000X
IDID-A3435452
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other