Healthcare Provider Details

I. General information

NPI: 1902380371
Provider Name (Legal Business Name): JEDD MOORE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MYRTLE ST STE 100
BOISE ID
83702-7690
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-472-9082
  • Fax:
Mailing address:
  • Phone: 208-955-6522
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number59377
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: