Healthcare Provider Details

I. General information

NPI: 1245568526
Provider Name (Legal Business Name): JENNIFER C BUKER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER C WADNER RD

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 E EXACTA LN
BOISE ID
83716-7197
US

IV. Provider business mailing address

3314 E EXACTA LN
BOISE ID
83716-7197
US

V. Phone/Fax

Practice location:
  • Phone: 208-994-9739
  • Fax:
Mailing address:
  • Phone: 208-994-9739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number974093
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: