Healthcare Provider Details

I. General information

NPI: 1902733421
Provider Name (Legal Business Name): JASON DALLIMORE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 E ST STE B
IDAHO FALLS ID
83402
US

IV. Provider business mailing address

254 E ST STE B
IDAHO FALLS ID
83402
US

V. Phone/Fax

Practice location:
  • Phone: 205-529-1854
  • Fax:
Mailing address:
  • Phone: 205-529-1854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-7662
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: