Healthcare Provider Details

I. General information

NPI: 1710185111
Provider Name (Legal Business Name): JESSICA ELAINE FU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 ELM STREET STE 310
CALDWELL ID
83605
US

IV. Provider business mailing address

315 ELM STREET STE 310
CALDWELL ID
83605
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-2035
  • Fax: 208-454-1065
Mailing address:
  • Phone: 208-454-2035
  • Fax: 208-454-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM-11303
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLL1756
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: