Healthcare Provider Details

I. General information

NPI: 1093648164
Provider Name (Legal Business Name): WHITNEY L JERRED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

IV. Provider business mailing address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5250
  • Fax: 208-667-2638
Mailing address:
  • Phone: 208-620-5250
  • Fax: 208-667-2638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8781716
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number43944
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: