Healthcare Provider Details

I. General information

NPI: 1639136351
Provider Name (Legal Business Name): JACKIE HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6749 W EDEN CT
RATHDRUM ID
83858-6423
US

IV. Provider business mailing address

6749 W EDEN CT
RATHDRUM ID
83858-6423
US

V. Phone/Fax

Practice location:
  • Phone: 208-687-2156
  • Fax:
Mailing address:
  • Phone: 208-687-2156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-258
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: