Healthcare Provider Details

I. General information

NPI: 1669115481
Provider Name (Legal Business Name): JARED M MALONE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 N IRONWOOD PL STE 100
COEUR D ALENE ID
83814-2670
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-769-4222
  • Fax: 844-803-7399
Mailing address:
  • Phone: 208-415-0299
  • Fax: 208-625-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number41928
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: