Provider Demographics
NPI:1073260311
Name:WOOD, JAKE A
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:A
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5760 S HAKKASAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-8803
Mailing Address - Country:US
Mailing Address - Phone:801-369-8569
Mailing Address - Fax:
Practice Address - Street 1:37 W ARCHERFIELD ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6587
Practice Address - Country:US
Practice Address - Phone:801-369-8569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ID75713451223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program