Provider Demographics
NPI:1538878293
Name:POELL, JENNA (DTCM)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:POELL
Suffix:
Gender:F
Credentials:DTCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8537
Mailing Address - Country:US
Mailing Address - Phone:208-994-4889
Mailing Address - Fax:
Practice Address - Street 1:1433 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8537
Practice Address - Country:US
Practice Address - Phone:208-994-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-451171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist