Healthcare Provider Details

I. General information

NPI: 1952425142
Provider Name (Legal Business Name): JANA M BRUNO MA, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

IV. Provider business mailing address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

V. Phone/Fax

Practice location:
  • Phone: 208-553-1785
  • Fax:
Mailing address:
  • Phone: 208-553-1785
  • Fax: 208-939-9110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLH61583717
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4152
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: