Provider Demographics
NPI:1659834000
Name:HALL, JACOB RICHARD
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RICHARD
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10255 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1430
Mailing Address - Country:US
Mailing Address - Phone:020-830-2560
Mailing Address - Fax:
Practice Address - Street 1:10255 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1430
Practice Address - Country:US
Practice Address - Phone:208-302-5600
Practice Address - Fax:208-302-5655
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-16234207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine