Provider Demographics
NPI:1518372846
Name:COOPERRIDER, JACLYN MARIE (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:COOPERRIDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:325 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6040
Practice Address - Country:US
Practice Address - Phone:208-514-2525
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13130207Q00000X, 207QS0010X
IDMRM-1390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1518372846Medicaid