Healthcare Provider Details

I. General information

NPI: 1750733184
Provider Name (Legal Business Name): JACOB LYNN NESTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE LYNN NESTLER

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 ALAN ST
IDAHO FALLS ID
83404-5801
US

IV. Provider business mailing address

2100 ALAN ST
IDAHO FALLS ID
83404-5801
US

V. Phone/Fax

Practice location:
  • Phone: 208-470-7979
  • Fax: 833-726-1877
Mailing address:
  • Phone: 208-470-7979
  • Fax: 833-726-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7551
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberP7551
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: