Healthcare Provider Details

I. General information

NPI: 1386039675
Provider Name (Legal Business Name): JACOB COMSTOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W PACIFIC ST
BLACKFOOT ID
83221-1726
US

IV. Provider business mailing address

2420E 25TH ST
IDAHO FALLS ID
83404-7549
US

V. Phone/Fax

Practice location:
  • Phone: 208-201-1743
  • Fax:
Mailing address:
  • Phone: 208-542-1026
  • Fax: 208-528-2945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCSW-34156
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: