Healthcare Provider Details

I. General information

NPI: 1790609477
Provider Name (Legal Business Name): GEN STATE INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST HERITAGE PARK LANE, SUITE 150 SUITE 150
MERIDIAN ID
83646
US

IV. Provider business mailing address

1500 EAST HERITAGE PARK LANE, SUITE 150 SUITE 150
MERIDIAN ID
83646
US

V. Phone/Fax

Practice location:
  • Phone: 208-202-7247
  • Fax: 208-202-7246
Mailing address:
  • Phone: 208-202-7247
  • Fax: 208-202-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER LYN PETRIE
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 208-365-7131