Healthcare Provider Details

I. General information

NPI: 1225299357
Provider Name (Legal Business Name): DEREK DEAN JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

777 N RAYMOND ST
BOISE ID
83704-9251
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6030
  • Fax: 208-322-7018
Mailing address:
  • Phone: 208-367-6030
  • Fax: 208-322-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMR-0989
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-10857
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: