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General NPI Number Information
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NPI Number | 1356123657
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Entity Type | Individual
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Provider Name | JEREMIAH ROBINS CLARK FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 10/20/2023
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 1526 W USTICK RD STE 110
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City | MERIDIAN
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State | ID
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Zip | 83646-7741
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Country | US
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Telephone | 208-370-5888
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Fax | 206-717-7104
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Provider Business Mailing Address
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Address Line | 8838 W PINE VALLEY LN
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City | BOISE
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State | ID
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Zip | 83709-0025
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Country | US
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Telephone | 269-428-7228
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | TEMP77813
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 77813
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License Number State | ID
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