Healthcare Provider Details

I. General information

NPI: 1255240453
Provider Name (Legal Business Name): JACOB SCHROEDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W SELTICE WAY
COEUR D ALENE ID
83814-8921
US

IV. Provider business mailing address

3700 W SELTICE WAY
COEUR D ALENE ID
83814-8921
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5210
  • Fax:
Mailing address:
  • Phone: 208-620-5210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7081036
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7081036
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7081036
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: