MEDICARE: DR. JACOB DOUGLAS ANDERSON DNP

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	363LF0000X	Family Nurse Practitioner	NP1718A	ID
2	261QX0100X	Occupational Medicine Clinic/Center
3	261QU0200X	Urgent Care Clinic/Center
4	363LF0000X	Family Nurse Practitioner	7942683-4405	UT
5	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1205300407	OTHER	ID	NPI
2	833011825	OTHER	ID	STATE

General Provider Information

NPI Number	:	1316329220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB DOUGLAS ANDERSON DNP

Provider Business Mailing Address
First Line	:	740 S WOODRUFF AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-5285
Country	:	US
Telephone Number	:	208-542-9111
Fax Number	:	208-542-9114

Provider Business Practice Location Address
First Line	:	630 E 1400 N STE 150
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2549
Country	:	US
Telephone Number	:	435-915-4465
Fax Number	:	435-787-8509

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

Provider Enumeration Date	:	06/26/2015
Last Update Date	:	06/15/2026

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