Healthcare Provider Details

I. General information

NPI: 1376905174
Provider Name (Legal Business Name): GEORJEAN KESSEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 IRONWOOD CT
COEUR D ALENE ID
83814-2628
US

IV. Provider business mailing address

2195 IRONWOOD CT
COEUR D ALENE ID
83814-2628
US

V. Phone/Fax

Practice location:
  • Phone: 208-769-2771
  • Fax: 208-769-1430
Mailing address:
  • Phone: 208-769-2771
  • Fax: 208-769-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-30297
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: