Healthcare Provider Details

I. General information

NPI: 1265941553
Provider Name (Legal Business Name): JENNIFER LEE WERSLAND PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

IV. Provider business mailing address

444 W FORT ST FL 2
BOISE ID
83702-4535
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1038
  • Fax:
Mailing address:
  • Phone: 208-422-1038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-202940
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: