Healthcare Provider Details

I. General information

NPI: 1679931224
Provider Name (Legal Business Name): SHWAN AL JAF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST SUITE 209
BOISE ID
83705-1966
US

IV. Provider business mailing address

8529 W FAIRVIEW AVE APT 207
BOISE ID
83704-8585
US

V. Phone/Fax

Practice location:
  • Phone: 208-918-7259
  • Fax:
Mailing address:
  • Phone: 208-918-7259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberW159670
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: