Healthcare Provider Details

I. General information

NPI: 1720099203
Provider Name (Legal Business Name): SALLY JO LEYSE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SALLY JO LEYSE LCPC

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601A PIONEER MOUNTAIN LOOP
JEROME ID
83338-6557
US

IV. Provider business mailing address

601A PIONEER MOUNTAIN LOOP
JEROME ID
83338-6557
US

V. Phone/Fax

Practice location:
  • Phone: 208-420-5902
  • Fax:
Mailing address:
  • Phone: 208-420-5902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-215
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: