Healthcare Provider Details

I. General information

NPI: 1104590751
Provider Name (Legal Business Name): JESSICA LYNN BRAY ANP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 350
COEUR D ALENE ID
83814-4487
US

IV. Provider business mailing address

700 W IRONWOOD DR STE 350
COEUR D ALENE ID
83814-4487
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5222
  • Fax: 208-625-5223
Mailing address:
  • Phone: 208-625-5222
  • Fax: 208-625-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9181316
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number182046
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: