Healthcare Provider Details

I. General information

NPI: 1750258224
Provider Name (Legal Business Name): JEANINE DICKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 225
MOYIE SPRINGS ID
83845-5000
US

IV. Provider business mailing address

PO BOX 225
MOYIE SPRINGS ID
83845-5000
US

V. Phone/Fax

Practice location:
  • Phone: 208-610-2566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number37965
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: