Provider Demographics
NPI:1063764462
Name:ACTIVE FAMILY HEALTHCARE PLLC
Entity type:Organization
Organization Name:ACTIVE FAMILY HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER NURSE PRACTIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-758-0560
Mailing Address - Street 1:919 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9764
Mailing Address - Country:US
Mailing Address - Phone:208-758-0560
Mailing Address - Fax:208-762-5424
Practice Address - Street 1:919 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-758-0560
Practice Address - Fax:208-762-5424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty