Provider Demographics
NPI:1750065462
Name:JERDE, ERIN MCKEEVER
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MCKEEVER
Last Name:JERDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15250 N WILDCAT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5021
Mailing Address - Country:US
Mailing Address - Phone:847-830-5045
Mailing Address - Fax:
Practice Address - Street 1:1431 N LIBERTY LAKE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-8522
Practice Address - Country:US
Practice Address - Phone:509-928-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAN361449896363LF0000X
ID67722363LF0000X
NYF337743-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily