Basic Information
| Provider Information | |||||||||
| NPI: | 1316329220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 S WOODRUFF AVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834015285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085429111 | ||||||||
| FaxNumber: | 2085429114 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 E 1400 N STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4359154465 | ||||||||
| FaxNumber: | 4357878509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 363LF0000X | 7942683-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1205300407 | 01 | ID | NPI | OTHER | 833011825 | 01 | ID | STATE | OTHER |