Healthcare Provider Details

I. General information

NPI: 1164140281
Provider Name (Legal Business Name): JESSICA MICHELLE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 E AMITY AVE
NAMPA ID
83686-1053
US

IV. Provider business mailing address

823 E AMITY AVE
NAMPA ID
83686-1053
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-8428
  • Fax: 800-934-4028
Mailing address:
  • Phone: 208-467-8428
  • Fax: 800-934-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number70287
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95015168
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70287
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number644524
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: