Healthcare Provider Details

I. General information

NPI: 1477858785
Provider Name (Legal Business Name): JACOB ATKINSON PSYD, ATR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 E RIVERPARK LN STE 220
BOISE ID
83706-6559
US

IV. Provider business mailing address

6568 S FEDERAL WAY BOX 235
BOISE ID
83716-9277
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-2071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5800
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY-203023
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: