Healthcare Provider Details

I. General information

NPI: 1477482602
Provider Name (Legal Business Name): JAMISON VINCENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 UNIVERSITY DR
BOISE ID
83725-0002
US

IV. Provider business mailing address

1283 S DIVISION AVE
BOISE ID
83706-3652
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1000
  • Fax:
Mailing address:
  • Phone: 734-352-1186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number6971051
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: