Healthcare Provider Details

I. General information

NPI: 1154947950
Provider Name (Legal Business Name): JACKIE LYN KAYNE-SHERAR PEER SUPPORT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE LYN SMITH

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 W PARK PL STE B
COEUR D ALENE ID
83814-2787
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5210
  • Fax: 844-807-3782
Mailing address:
  • Phone: 208-415-0299
  • Fax: 208-625-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number0
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: