Individual
GLENN E JEFFERSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2315 8TH ST, LEWISTON, ID 83501-7301
(208) 746-1383
(208) 746-6348
Mailing address
2315 8TH ST, LEWISTON, ID 83501-7301
(208) 746-1383
(208) 746-6348
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M4593
ID
207Q00000X
Family Medicine Physician
MD00025241
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1007806
—
WA
01
—
1119637
DMERC
ID
01
—
1326121286
HEALTHY CONNECTIONS
ID
05
—
1326121286
—
ID
01
—
31254
LABOR & INDUSTRIES
WA
01
—
80094289
RAILROAD MEDICARE
ID
01
—
DF540
BLUE CROSS
ID
Enumeration date
10/23/2006
Last updated
03/08/2016
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