Provider Demographics
NPI:1548016082
Name:JARA, MICHAEL BENJAMIN (PMHNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:JARA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 S COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4625
Mailing Address - Country:US
Mailing Address - Phone:209-598-0092
Mailing Address - Fax:
Practice Address - Street 1:2020 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6707
Practice Address - Country:US
Practice Address - Phone:208-518-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60757363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health