Healthcare Provider Details

I. General information

NPI: 1568954659
Provider Name (Legal Business Name): JENNIFER A WERT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 UNIVERSITY AVE E
GOODING ID
83330-6155
US

IV. Provider business mailing address

1956 WOOD RIVER RD
GOODING ID
83330-6105
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-5880
  • Fax:
Mailing address:
  • Phone: 208-420-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-37730
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: