Basic Information
| Provider Information | |||||||||
| NPI: | 1558808501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAKSIEK | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4060 WESTOWN PKWY | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502661010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152250188 | ||||||||
| FaxNumber: | 5152250971 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 N CURTIS ROAD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083022000 | ||||||||
| FaxNumber: | 2083022055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2017 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A106999 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 55656 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.