Provider Demographics
NPI:1356123657
Name:CLARK, JEREMIAH ROBINS (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:ROBINS
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8838 W PINE VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0025
Mailing Address - Country:US
Mailing Address - Phone:269-428-7228
Mailing Address - Fax:
Practice Address - Street 1:1526 W USTICK RD STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7741
Practice Address - Country:US
Practice Address - Phone:208-370-5888
Practice Address - Fax:206-717-7104
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTEMP77813363LF0000X
ID77813363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily