Healthcare Provider Details

I. General information

NPI: 1235814344
Provider Name (Legal Business Name): JERRY NABARRETE-STUART JR. LSMW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6933 W EMERALD ST
BOISE ID
83704-8616
US

IV. Provider business mailing address

6933 W EMERALD ST
BOISE ID
83704-8616
US

V. Phone/Fax

Practice location:
  • Phone: 208-321-0634
  • Fax: 208-321-1082
Mailing address:
  • Phone: 208-321-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLMSW-43688
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: