Basic Information
| Provider Information | |||||||||
| NPI: | 1790400992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | THERESE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 N IRON BRIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992024932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1203 IDAHO ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835011940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2022 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN00124469 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 72977 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.