Healthcare Provider Details

I. General information

NPI: 1225597305
Provider Name (Legal Business Name): LYLE JEREMY JACKSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

1090 BARNEY DAIRY RD
REXBURG ID
83440-3542
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-2700
  • Fax:
Mailing address:
  • Phone: 801-319-9345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number125895
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD183481
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number62439
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: