Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D-5055 | ID |
NPI | 1003478629 |
---|---|
Provider Name | Chris R Jackson |
First Address | Boise, ID 83704-4375 |
Second Address | Meridian, ID 83642 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2019 |
Last Update Date | 03/07/2019 |