Basic Information
| Provider Information | |||||||||
| NPI: | 1841868239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHALK | ||||||||
| FirstName: | JACKIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 LARAMIE AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836445846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034535812 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 68558 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.