Healthcare Provider Details

I. General information

NPI: 1841668761
Provider Name (Legal Business Name): JERILYN TAYLOR MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JERILYN KEJICK ACADC

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 HOOPES AVE
IDAHO FALLS ID
83401-6106
US

IV. Provider business mailing address

615 HOOPES AVE
IDAHO FALLS ID
83401-6106
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-0352
  • Fax: 208-542-0359
Mailing address:
  • Phone: 208-542-0352
  • Fax: 208-542-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number03 197
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-6094
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: