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NPI Code Detail

MEDICARE: MR. JEREMY WAYNE IRVIN LCSW, MED

MEDICARE: MR. JEREMY WAYNE IRVIN LCSW, MED
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
11041C0700XClinical Social WorkerLCSW-36060ID

General Provider Information

NPI Number : 1245684927
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JEREMY WAYNE IRVIN LCSW, MED
Provider Business Mailing Address
First Line : 3278 E RENWICK ST
Second Line :
City : MERIDIAN
State : ID
Zip : 83642-6467
Country : US
Telephone Number : 208-417-8428
Fax Number : 208-216-1434
Provider Business Practice Location Address
First Line : 6003 W OVERLAND RD STE 105
Second Line :
City : BOISE
State : ID
Zip : 83709-3075
Country : US
Telephone Number : 208-417-8428
Fax Number : 208-216-1434
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/19/2016
Last Update Date : 12/10/2021

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