Healthcare Provider Details

I. General information

NPI: 1659834000
Provider Name (Legal Business Name): JACOB RICHARD HALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10255 W OVERLAND RD
BOISE ID
83709-1430
US

IV. Provider business mailing address

10255 W OVERLAND RD
BOISE ID
83709-1430
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5600
  • Fax: 208-302-5655
Mailing address:
  • Phone: 20-830-2560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-16234
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: