Provider Demographics
NPI:1407738289
Name:ERICKSON, JACOB LEON (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LEON
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:3115 E FLORENCE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1586
Practice Address - Country:US
Practice Address - Phone:208-991-2963
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8971560122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist