Healthcare Provider Details

I. General information

NPI: 1568178473
Provider Name (Legal Business Name): JOANNA HANCOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 BELMONT ST.
BOISE ID
83706
US

IV. Provider business mailing address

3341 S GRENZE WAY
MERIDIAN ID
83642-8673
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1459
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-9286
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: