Healthcare Provider Details

I. General information

NPI: 1912801382
Provider Name (Legal Business Name): JACLYN CHARLENE RICHMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 E PARK BLVD STE 100
BOISE ID
83712-7722
US

IV. Provider business mailing address

PO BOX 696
IDAHO CITY ID
83631-0696
US

V. Phone/Fax

Practice location:
  • Phone: 208-369-9168
  • Fax:
Mailing address:
  • Phone: 208-992-7219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: