Healthcare Provider Details

I. General information

NPI: 1770961500
Provider Name (Legal Business Name): JEREMY KENDALL LPC, QMHP, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
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

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5255
  • Fax:
Mailing address:
  • Phone: 208-415-0299
  • Fax: 605-718-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-9460
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: