Provider Demographics
NPI:1043818800
Name:HINCKLEY, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:HINCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 WHITEWATER DR APT 15201
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5278
Mailing Address - Country:US
Mailing Address - Phone:208-360-2749
Mailing Address - Fax:
Practice Address - Street 1:960 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1912
Practice Address - Country:US
Practice Address - Phone:208-785-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP9112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist