Healthcare Provider Details

I. General information

NPI: 1538412382
Provider Name (Legal Business Name): JASON SOUTHWICK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2121
  • Fax:
Mailing address:
  • Phone: 82-367-2121
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY - 202728
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY - 202728
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: