Provider Demographics
NPI:1679675391
Name:JACKSON, KERI LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:KERI
Middle Name:LYNN
Last Name:JACKSON
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:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0139
Mailing Address - Country:US
Mailing Address - Phone:208-451-5072
Mailing Address - Fax:
Practice Address - Street 1:1521 W ALTURAS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3419
Practice Address - Country:US
Practice Address - Phone:650-388-6286
Practice Address - Fax:208-343-4051
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50592207P00000X
IDM-13124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine