Healthcare Provider Details

I. General information

NPI: 1508206624
Provider Name (Legal Business Name): JIM B SMITH LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 23RD ST
BOISE ID
83702-9100
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-1170
  • Fax: 208-345-3502
Mailing address:
  • Phone: 208-467-4431
  • Fax: 208-467-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-33117
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: