Provider Demographics
NPI:1316329220
Name:ANDERSON, JACOB DOUGLAS (DNP)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DOUGLAS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:740 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5285
Mailing Address - Country:US
Mailing Address - Phone:208-542-9111
Mailing Address - Fax:208-542-9114
Practice Address - Street 1:630 E 1400 N STE 150
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2549
Practice Address - Country:US
Practice Address - Phone:435-915-4465
Practice Address - Fax:435-787-8509
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QX0100X, 261QP2300X, 261QU0200X
UT7942683-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1205300407OtherNPI
ID833011825OtherSTATE