Healthcare Provider Details

I. General information

NPI: 1164673968
Provider Name (Legal Business Name): JENIFER L BARRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 S OWYHEE ST
BOISE ID
83705-6014
US

IV. Provider business mailing address

1525 S OWYHEE ST
BOISE ID
83705-6014
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-8482
  • Fax: 208-345-5426
Mailing address:
  • Phone: 208-344-8482
  • Fax: 208-345-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM11233
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA112311
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-11233
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: