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General NPI Number Information
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NPI Number | 1720450067
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Entity Type | Individual
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Provider Name | JACQUELYNE RENEE ANTON NBC-HWC AND M.S.
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Gender | Female
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Dates
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Enumeration Date | 10/27/2015
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Last Update Date | 01/24/2022
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Provider Practice Location Address
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Address Line | 4100 E WILDHORSE LN
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City | BOISE
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State | ID
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Zip | 83712-7593
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Country | US
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Telephone | 704-608-1568
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Fax |
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Provider Business Mailing Address
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Address Line | 4100 E WILDHORSE LN
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City | BOISE
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State | ID
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Zip | 83712-7593
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Country | US
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Telephone | 704-608-1568
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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 | 247200000X
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Taxonomy Name | Other Technician
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License Number | PSG-055
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number | ID-A3435452
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License Number State | ID
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