Healthcare Provider Details

I. General information

NPI: 1407368616
Provider Name (Legal Business Name): JESSICA OWSLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 E ST STE B
IDAHO FALLS ID
83402-3527
US

IV. Provider business mailing address

254 E ST STE B
IDAHO FALLS ID
83402-3527
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-1854
  • Fax:
Mailing address:
  • Phone: 208-529-1854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-40308
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: