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CLUBHOUSE PEDIATRIC DENTISTRY OF IDAHO FALLS PLLC

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Company Details

Name: CLUBHOUSE PEDIATRIC DENTISTRY OF IDAHO FALLS PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 10 Sep 2018 (7 years ago)
Financial Date End: 30 Sep 2026
Entity Number: 624677
Place of Formation: IDAHO
File Number: 624677
ZIP code: 83404
County: Bonneville County
Principal Address: 3411 MERLIN DR # 100 IDAHO FALLS, ID 83404-7430

Agent

Name Role Address
Courtney M Jackson Agent 3981 NOTTINGHAM LN, IDAHO FALLS, ID 83402

Manager

Name Role Address Appointed On
Courtney M Jackson Manager 3411 MERLIN DR # 100, IDAHO FALLS, ID 83404-7430 2020-09-24

National Provider Identifier

NPI Number:
1376028324

Authorized Person:

Name:
MRS. JENNIFER LOUISE ROBISON
Role:
CREDENTIALING COORDINATOR
Phone:

Taxonomy:

Selected Taxonomy:
1223P0221X - Pediatric Dentist
Is Primary:
Yes

Contacts:

Filing

Filing Name Filing Number Filing date
Annual Report 0006398304 2025-08-12
Annual Report 0005855966 2024-08-12
Annual Report 0005352661 2023-08-04
Annual Report 0004865622 2022-08-19
Change of Registered Office/Agent/Both (by Entity) 0004806242 2022-07-06

USAspending Awards / Financial Assistance

Date:
2020-04-16
Awarding Agency Name:
Small Business Administration
Transaction Description:
TO AID SMALL BUSINESSES IN MAINTAINING WORK FORCE DURING COVID-19 PANDEMIC.
Obligated Amount:
0.00
Face Value Of Loan:
4000.00
Total Face Value Of Loan:
4000.00
Date:
2020-04-16
Awarding Agency Name:
Small Business Administration
Transaction Description:
TO AID SMALL BUSINESSES IN MAINTAINING WORK FORCE DURING COVID-19 PANDEMIC.
Obligated Amount:
0.00
Face Value Of Loan:
4000.00
Total Face Value Of Loan:
4000.00

Paycheck Protection Program

Jobs Reported:
9
Initial Approval Amount:
$4,000
Date Approved:
2020-04-15
Loan Status:
Paid in Full
SBA Guaranty Percentage:
100
Current Approval Amount:
$4,000
Race:
Unanswered
Ethnicity:
Unknown/NotStated
Gender:
Unanswered
Veteran:
Unanswered
Forgiveness Amount:
$4,054.79
Servicing Lender:
Zions Bank, A Division of
Use of Proceeds:
Payroll: $4,000

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Date of last update: 14 Aug 2025

Sources: Idaho Secretary of State