Individual
DR. JENNIFER A. SOUTHARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
6533 EMERALD STREET, BOISE, ID 83704-8737
(208) 302-5100
(208) 302-5155
Mailing address
3340 EAST GOLDSTONE WAY, MERIDIAN, ID 83642
(208) 302-5100
(208) 302-5155
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M-11245
ID
207Q00000X
Family Medicine Physician
RS2000-0386
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
RS2000-0386
TRAINING LICENSE
NM
Enumeration date
07/05/2007
Last updated
11/17/2016
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