Healthcare Provider Details

I. General information

NPI: 1679723282
Provider Name (Legal Business Name): JESSICA SHAKESPEARE NEIGHBORS PSYD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S BRIDGEWAY PL STE 280
EAGLE ID
83616-6834
US

IV. Provider business mailing address

1025 S BRIDGEWAY PL STE 280
EAGLE ID
83616-6834
US

V. Phone/Fax

Practice location:
  • Phone: 208-412-7740
  • Fax: 208-853-1318
Mailing address:
  • Phone: 208-412-7740
  • Fax: 208-853-1318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY203874
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28825
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: