Healthcare Provider Details

I. General information

NPI: 1699692020
Provider Name (Legal Business Name): DEANDRE JONES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST STE 110
BOISE ID
83705
US

IV. Provider business mailing address

4369 E VACHERON ST
MERIDIAN ID
83642-5428
US

V. Phone/Fax

Practice location:
  • Phone: 208-919-4692
  • Fax:
Mailing address:
  • Phone: 986-268-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberZH475896I
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: