Healthcare Provider Details

I. General information

NPI: 1043188998
Provider Name (Legal Business Name): JUSTINE LYNNETTE KOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N CAPITAL AVE STE 1
IDAHO FALLS ID
83402-3405
US

IV. Provider business mailing address

855 N CAPITAL AVE STE 1
IDAHO FALLS ID
83402-3405
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-0855
  • Fax: 208-523-1132
Mailing address:
  • Phone: 208-552-0855
  • Fax: 208-523-1132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9481039
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: