Healthcare Provider Details

I. General information

NPI: 1699413757
Provider Name (Legal Business Name): WILD LIFE COMMUNITY COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 BLACK MOUNTAIN RD
BONNERS FERRY ID
83805-5308
US

IV. Provider business mailing address

PO BOX 172
BONNERS FERRY ID
83805-0172
US

V. Phone/Fax

Practice location:
  • Phone: 208-416-3850
  • Fax:
Mailing address:
  • Phone: 208-416-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DEAN MICHAEL JENNINGS
Title or Position: LCSW
Credential: LCSW
Phone: 208-416-3850