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General NPI Number Information
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NPI Number | 1679675391
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Entity Type | Individual
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Provider Name | KERI LYNN JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 09/02/2006
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 1521 W ALTURAS ST
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City | BOISE
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State | ID
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Zip | 83702-3419
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Country | US
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Telephone | 650-388-6286
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Fax | 208-343-4051
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Provider Business Mailing Address
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Address Line | PO BOX 139
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City | BOISE
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State | ID
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Zip | 83701-0139
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Country | US
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Telephone | 208-451-5072
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | C50592
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-13124
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License Number State | ID
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