Provider Demographics
NPI:1730582271
Name:SANDERSON, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNI
Other - Middle Name:
Other - Last Name:SANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:190 W BURNSIDE
Mailing Address - Street 2:STE C
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2411
Mailing Address - Country:US
Mailing Address - Phone:208-417-8842
Mailing Address - Fax:833-728-0327
Practice Address - Street 1:190 W BURNSIDE
Practice Address - Street 2:STE C
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2411
Practice Address - Country:US
Practice Address - Phone:208-417-8842
Practice Address - Fax:833-728-0327
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1511A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1679183388Medicaid