Individual
JACLYN MARIE COOPERRIDER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
325 W IDAHO ST, BOISE, ID 83702-6040
(208) 514-2525
(208) 375-2217
Mailing address
777 N RAYMOND ST, BOISE, ID 83704-9251
(208) 514-2500
(208) 375-2217
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M-13130
ID
207Q00000X
Family Medicine Physician
MRM-1390
ID
207QS0010X
Sports Medicine (Family Medicine) Physician
M-13130
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1518372846
—
ID
Enumeration date
06/25/2014
Last updated
12/15/2023
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