Healthcare Provider Details

I. General information

NPI: 1225992340
Provider Name (Legal Business Name): JACKIE UMUTONI KAMANZI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11443 W ANNATA ST
NAMPA ID
83651-4360
US

IV. Provider business mailing address

11443 W ANNATA ST
NAMPA ID
83651-4360
US

V. Phone/Fax

Practice location:
  • Phone: 208-515-1187
  • Fax:
Mailing address:
  • Phone: 208-515-1187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: