Healthcare Provider Details

I. General information

NPI: 1487880001
Provider Name (Legal Business Name): JAIME LEA MCCLURE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 05/14/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 42ND ST
DES MOINES IA
50312-2701
US

IV. Provider business mailing address

600 42ND ST
DES MOINES IA
50312-2701
US

V. Phone/Fax

Practice location:
  • Phone: 515-255-8399
  • Fax: 515-255-8405
Mailing address:
  • Phone: 515-255-8399
  • Fax: 515-255-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00124
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number007728
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: