Healthcare Provider Details

I. General information

NPI: 1417733593
Provider Name (Legal Business Name): JENNIFER HANCOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
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

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-208-5255
  • Fax:
Mailing address:
  • Phone: 208-415-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8911444
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: