Healthcare Provider Details

I. General information

NPI: 1851258784
Provider Name (Legal Business Name): WILD ROSE MENTAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 SHOUP AVE STE 313
IDAHO FALLS ID
83402-3650
US

IV. Provider business mailing address

7761 N 55TH E
IDAHO FALLS ID
83401-5530
US

V. Phone/Fax

Practice location:
  • Phone: 986-294-0262
  • Fax:
Mailing address:
  • Phone: 986-294-0262
  • Fax: 208-693-9024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JESSICA COLBERT
Title or Position: OWNER/MANAGER
Credential: LCSW
Phone: 986-294-0262