Healthcare Provider Details

I. General information

NPI: 1326105206
Provider Name (Legal Business Name): JACKIE J TURNIPSEED-AYMON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 STATE ST
MCCALL ID
83638-3704
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-1776
  • Fax: 208-634-3873
Mailing address:
  • Phone: 208-634-1776
  • Fax: 208-634-3873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA242
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: