Healthcare Provider Details

I. General information

NPI: 1649793738
Provider Name (Legal Business Name): JESSICA RAE KIRWAN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 BELMONT ST
BOISE ID
83706
US

IV. Provider business mailing address

11103 RIPLEY CT
BOISE ID
83713-2672
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1459
  • Fax:
Mailing address:
  • Phone: 208-850-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-9390
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: