Healthcare Provider Details

I. General information

NPI: 1790833424
Provider Name (Legal Business Name): MJ COUNSELING AND CASE MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2328 MOUNTAIN VIEW DR BOX 130
EMMETT ID
83617-9533
US

IV. Provider business mailing address

2328 MOUNTAIN VIEW DR BOX 130
EMMETT ID
83617-9533
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-3183
  • Fax: 208-365-2307
Mailing address:
  • Phone: 208-365-3183
  • Fax: 208-365-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberC148733
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberC148733
License Number StateID

VIII. Authorized Official

Name: MRS. LEE ANN JONES
Title or Position: OWNERADMINISTRATOR
Credential: LCSW
Phone: 208-365-3183