Healthcare Provider Details

I. General information

NPI: 1598151508
Provider Name (Legal Business Name): JESSE HINCKLEY MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 E 25TH ST
IDAHO FALLS ID
83404-7542
US

IV. Provider business mailing address

PO BOX 742358
ATLANTA GA
30374-2358
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number59845
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-17310
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM-17310
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: