1154311199 NPI number — MRS. JEANNETTE E JAIN M.D.

Table of content: MRS. JEANNETTE E JAIN M.D. (NPI 1154311199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154311199 NPI number — MRS. JEANNETTE E JAIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAIN
Provider First Name:
JEANNETTE
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
JEANNETTE
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154311199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 E HAWAII AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83686-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-463-3000
Provider Business Mailing Address Fax Number:
208-463-3034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 E HAWAII AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-468-5930
Provider Business Practice Location Address Fax Number:
208-463-3044
Provider Enumeration Date:
10/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  M8205 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806061800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010032978 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 42507 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 080036991 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806353400 . This is a "HEALTHY CONNECTIONS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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