Healthcare Provider Details

I. General information

NPI: 1740632983
Provider Name (Legal Business Name): JESSICA CROSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 EMERALD DR
KELLOGG ID
83837-2231
US

IV. Provider business mailing address

PO BOX 695
KELLOGG ID
83837-0695
US

V. Phone/Fax

Practice location:
  • Phone: 208-512-1027
  • Fax:
Mailing address:
  • Phone: 208-512-1027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: