Healthcare Provider Details

I. General information

NPI: 1528690179
Provider Name (Legal Business Name): JEREMIAH OSBORN LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 S ORCHARD ST STE 101
BOISE ID
83705-1916
US

IV. Provider business mailing address

921 S ORCHARD ST STE 101
BOISE ID
83705-1916
US

V. Phone/Fax

Practice location:
  • Phone: 208-629-2436
  • Fax: 208-712-6778
Mailing address:
  • Phone: 208-420-3018
  • Fax: 208-712-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW-38962
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: