Individual
LYLE JEREMY JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
2325 CORONADO ST, IDAHO FALLS, ID 83404-7407
(208) 557-2700
Mailing address
1090 BARNEY DAIRY RD, REXBURG, ID 83440-3542
(801) 319-9345
Taxonomy
Speciality
Code
Description
License number
State
163WX0800X
Orthopedic Registered Nurse
Primary
62439
ID
367500000X
Certified Registered Nurse Anesthetist
125895
VA
367500000X
Certified Registered Nurse Anesthetist
D183481
IA
Other
Enumeration date
03/18/2019
Last updated
06/30/2025
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