Healthcare Provider Details

I. General information

NPI: 1417861535
Provider Name (Legal Business Name): JEREMY DANIEL POWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6945 W EMERALD ST
BOISE ID
83704-8616
US

IV. Provider business mailing address

5290 W ELLENS FERRY DR
BOISE ID
83703-3152
US

V. Phone/Fax

Practice location:
  • Phone: 208-515-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8781322
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: