MEDICARE: ALYSSA MAY JACK PA-C

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	363A00000X	Physician Assistant	PA-1966	ID

General Provider Information

NPI Number	:	1598357436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA MAY JACK PA-C

Provider Business Mailing Address
First Line	:	4095 E MENAN LORENZO HWY
Second Line	:
City	:	RIGBY
State	:	ID
Zip	:	83442-5169
Country	:	US
Telephone Number	:	208-847-5762
Fax Number	:	208-963-3245

Provider Business Practice Location Address
First Line	:	535 W SUNNYSIDE RD STE 2
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-4647
Country	:	US
Telephone Number	:	208-357-9700
Fax Number	:	208-963-3245

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

Provider Enumeration Date	:	02/10/2021
Last Update Date	:	06/17/2025

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