MEDICARE: NICHOLE JORDAN M. COUN., LCPC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LCPC-4471	ID
2	101YM0800X	Mental Health Counselor	LCPC-4471	ID

General Provider Information

NPI Number	:	1073744066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE JORDAN M. COUN., LCPC, NCC

Provider Business Mailing Address
First Line	:	3350 W AMERICANA TER
Second Line	:	SUITE #215
City	:	BOISE
State	:	ID
Zip	:	83706-2521
Country	:	US
Telephone Number	:	208-342-7030
Fax Number	:	208-342-7030

Provider Business Practice Location Address
First Line	:	3350 W AMERICANA TER
Second Line	:	SUITE #215
City	:	BOISE
State	:	ID
Zip	:	83706-2521
Country	:	US
Telephone Number	:	208-342-7030
Fax Number	:	208-342-7030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2009
Last Update Date	:	07/17/2011

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