Healthcare Provider Details

I. General information

NPI: 1821485012
Provider Name (Legal Business Name): JENNIFER JEAN MIMISH CNM, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER JEAN NAVARRO CNM, WHNP

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S MILLSTREAM DR
NAMPA ID
83686-4837
US

IV. Provider business mailing address

1301 S MILLSTREAM DR
NAMPA ID
83686-4837
US

V. Phone/Fax

Practice location:
  • Phone: 208-352-2290
  • Fax:
Mailing address:
  • Phone: 208-559-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License NumberNP1553A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM84A
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP1553A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: