Healthcare Provider Details

I. General information

NPI: 1831009984
Provider Name (Legal Business Name): JONATHAN WARREN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N LATAH ST
BOISE ID
83706-2622
US

IV. Provider business mailing address

12 N LATAH ST
BOISE ID
83706-2622
US

V. Phone/Fax

Practice location:
  • Phone: 865-696-5746
  • Fax:
Mailing address:
  • Phone: 865-696-5746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4781228
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: