Provider Demographics
NPI:1811799372
Name:ANDERSEN, JACOB REX
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:REX
Last Name:ANDERSEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3971 JOSHUA LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-1778
Mailing Address - Country:US
Mailing Address - Phone:208-881-7679
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:623-561-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program