1669573929 NPI number — JESSICA BERRYMAN JAMESON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669573929 NPI number — JESSICA BERRYMAN JAMESON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAMESON
Provider First Name:
JESSICA
Provider Middle Name:
BERRYMAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERRYMAN
Provider Other First Name:
JESSICA
Provider Other Middle Name:
LEE
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:
1669573929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1593 E POLSTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POST FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83854-5326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-262-2300
Provider Business Mailing Address Fax Number:
208-262-2390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1641 E POLSTON AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-7852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-457-4208
Provider Business Practice Location Address Fax Number:
208-457-4197
Provider Enumeration Date:
09/26/2006

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: 207L00000X , with the licence number:  M-11915 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: M-11915 , 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: 1669573929 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com