Provider Demographics
NPI:1215972831
Name:VINCENT, JENNIFER M (DO)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:VINCENT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6503
Practice Address - Street 1:11197 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7935
Practice Address - Country:US
Practice Address - Phone:208-378-8011
Practice Address - Fax:208-322-8095
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805092900Medicaid
ID805092900Medicaid
G88643Medicare UPIN
ID1301879Medicare PIN