Healthcare Provider Details

I. General information

NPI: 1467605642
Provider Name (Legal Business Name): AMY K JEPPESEN L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 W EMERALD ST SUITE 178
BOISE ID
83704-4854
US

IV. Provider business mailing address

8950 W EMERALD ST SUITE 178
BOISE ID
83704-4854
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-7083
  • Fax: 208-321-5069
Mailing address:
  • Phone: 208-376-7083
  • Fax: 208-321-5069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number374774-3501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-27936
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: