Healthcare Provider Details

I. General information

NPI: 1700830882
Provider Name (Legal Business Name): JEREMY HENRY CONKLIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2006
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N CURTIS RD STE 415
BOISE ID
83706-1334
US

IV. Provider business mailing address

747 BROADWAY
SEATTLE WA
98122-4307
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2600
  • Fax: 208-302-2625
Mailing address:
  • Phone: 206-215-2520
  • Fax: 206-215-6364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberOP60816242
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberCDR.0002122
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License NumberCDR.0002122
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberOC-0435
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: