Healthcare Provider Details

I. General information

NPI: 1316329220
Provider Name (Legal Business Name): JACOB DOUGLAS ANDERSON DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E 1400 N STE 150
LOGAN UT
84341-2549
US

IV. Provider business mailing address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

V. Phone/Fax

Practice location:
  • Phone: 435-915-4465
  • Fax: 435-787-8509
Mailing address:
  • Phone: 208-542-9111
  • Fax: 208-542-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1718A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7942683-4405
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: