Healthcare Provider Details

I. General information

NPI: 1700063559
Provider Name (Legal Business Name): JENNIFER A. WILSON C.S.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 W EMERALD ST
BOISE ID
83704-8736
US

IV. Provider business mailing address

6500 W EMERALD ST
BOISE ID
83704-8736
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-0777
  • Fax: 208-377-1070
Mailing address:
  • Phone: 208-377-0777
  • Fax: 208-377-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number89338
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: