MEDICARE: SUSAN JEROME NP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	NP234-A	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NP234A	OTHER	ID	STATE LICENSE

General Provider Information

NPI Number	:	1265650238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN JEROME NP

Provider Business Mailing Address
First Line	:	1910 UNIVERSITY DR
Second Line	:	MS-1351
City	:	BOISE
State	:	ID
Zip	:	83725-0002
Country	:	US
Telephone Number	:	208-426-1459
Fax Number	:	208-426-3005

Provider Business Practice Location Address
First Line	:	1910 UNIVERSITY DR
Second Line	:	MS-1351
City	:	BOISE
State	:	ID
Zip	:	83725-0002
Country	:	US
Telephone Number	:	208-426-1459
Fax Number	:	208-426-3005

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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