=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164140281
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA MICHELLE ANDERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2022
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 823 E AMITY AVE
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-1053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-8428
-----------------------------------------------------
Fax | 800-934-4028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 823 E AMITY AVE
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-1053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-8428
-----------------------------------------------------
Fax | 800-934-4028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 70287
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95015168
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 70287
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 644524
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------