Healthcare Provider Details

I. General information

NPI: 1922912435
Provider Name (Legal Business Name): JORDAN PATRICK RAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 E 17TH ST STE B
IDAHO FALLS ID
83404-8042
US

IV. Provider business mailing address

2065 E 17TH ST STE B
IDAHO FALLS ID
83404-8042
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-6053
  • Fax:
Mailing address:
  • Phone: 208-520-6053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5181639
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: