Healthcare Provider Details

I. General information

NPI: 1154311199
Provider Name (Legal Business Name): JEANNETTE E JAIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANNETTE E BENNETT MD

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

IV. Provider business mailing address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

V. Phone/Fax

Practice location:
  • Phone: 208-468-5930
  • Fax: 208-463-3044
Mailing address:
  • Phone: 208-463-3000
  • Fax: 208-463-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM8205
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: