Healthcare Provider Details

I. General information

NPI: 1740962315
Provider Name (Legal Business Name): JACKELLE N KNICKREHM LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKELLE MILLER

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 01/07/2025
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ACADEMY AVE
EAGLE ID
83616
US

IV. Provider business mailing address

136 S ACADEMY AVE
EAGLE ID
83616
US

V. Phone/Fax

Practice location:
  • Phone: 208-254-1112
  • Fax: 208-939-9110
Mailing address:
  • Phone: 208-254-1112
  • Fax: 208-939-9110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLMSW-35335
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: