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General NPI Number Information
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NPI Number | 1780553073
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Entity Type | Individual
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Provider Name | JESSE WILLE
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Gender | Female
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Dates
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Enumeration Date | 11/04/2025
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Last Update Date | 11/04/2025
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Provider Practice Location Address
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Address Line | 550 2ND ST STE 248
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3974
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Country | US
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Telephone | 208-590-7464
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Fax |
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Provider Business Mailing Address
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Address Line | 397 THOMSON FARMS RD UNIT 4109
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City | REXBURG
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State | ID
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Zip | 83440-4998
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Country | US
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Telephone |
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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 | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MAS-3752
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License Number State | ID
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