Healthcare Provider Details

I. General information

NPI: 1891115499
Provider Name (Legal Business Name): JENNA WHAITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

IV. Provider business mailing address

8515 E DROVER LOOP
NAMPA ID
83687-8506
US

V. Phone/Fax

Practice location:
  • Phone: 208-254-1112
  • Fax:
Mailing address:
  • Phone: 208-505-8657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number40339
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: