MEDICARE: JESSICA MICHELLE ANDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	70287	ID
2	363L00000X	Nurse Practitioner	95015168	CA
3	207Q00000X	Family Medicine Physician	70287	ID
4	207Q00000X	Family Medicine Physician	644524	CA

General Provider Information

NPI Number	:	1164140281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MICHELLE ANDERSON

Provider Business Mailing Address
First Line	:	823 E AMITY AVE
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-1053
Country	:	US
Telephone Number	:	208-467-8428
Fax Number	:	800-934-4028

Provider Business Practice Location Address
First Line	:	823 E AMITY AVE
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-1053
Country	:	US
Telephone Number	:	208-467-8428
Fax Number	:	800-934-4028

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	12/05/2025

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Directions to “ JESSICA MICHELLE ANDERSON ” Practice Location

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