Healthcare Provider Details

I. General information

NPI: 1891646055
Provider Name (Legal Business Name): TETON RIVER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1ST ST
DRIGGS ID
83422-5219
US

IV. Provider business mailing address

30 N 1ST ST
DRIGGS ID
83422-5219
US

V. Phone/Fax

Practice location:
  • Phone: 208-435-8846
  • Fax:
Mailing address:
  • Phone: 208-435-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSICA MADDOX
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 801-870-6890