Healthcare Provider Details

I. General information

NPI: 1003409913
Provider Name (Legal Business Name): JENNIFER LYTLE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 W USTICK RD STE 110
MERIDIAN ID
83646-7741
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-370-5888
  • Fax:
Mailing address:
  • Phone: 208-985-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number67384
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number67384
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: