Healthcare Provider Details

I. General information

NPI: 1790785335
Provider Name (Legal Business Name): JACQUELYN WOLF HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 N COLE RD
BOISE ID
83704-8642
US

IV. Provider business mailing address

9532 W KATE DR
BOISE ID
83714-4053
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-0019
  • Fax: 208-377-0313
Mailing address:
  • Phone: 208-854-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberH1017
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: