Provider Demographics
NPI:1285779496
Name:STEVENSON, JAYNE (MD)
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W BANNOCK ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5837
Mailing Address - Country:US
Mailing Address - Phone:208-336-7341
Mailing Address - Fax:208-336-7342
Practice Address - Street 1:802 W BANNOCK ST
Practice Address - Street 2:SUITE 405
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5837
Practice Address - Country:US
Practice Address - Phone:208-336-7341
Practice Address - Fax:208-336-7342
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8899173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147087OtherREGENCE BLUE SHIELD
ID75739OtherBLUE CROSS OF IDAHO
H80850Medicare UPIN