Individual
JACOB SUP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
2005 ARLINGTON AVE, CALDWELL, ID 83605-4808
(208) 459-1025
(208) 459-1080
Mailing address
PO BOX 9, NAMPA, ID 83653-0009
(208) 467-4431
(208) 466-5359
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
O-1402
ID
Other
Enumeration date
03/21/2017
Last updated
08/07/2020
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