Provider Demographics
NPI:1154947950
Name:KAYNE-SHERAR, JACKIE LYN (PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYN
Last Name:KAYNE-SHERAR
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:2025 W PARK PL STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2787
Practice Address - Country:US
Practice Address - Phone:208-620-5210
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCA137433GOtherDRIVERS LICENSE