Healthcare Provider Details

I. General information

NPI: 1184282303
Provider Name (Legal Business Name): JESSICA DIAZ LCPC, NCC, ICADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA HINKLE

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E PORTER ST
KUNA ID
83634-1484
US

IV. Provider business mailing address

711 E PORTER ST
KUNA ID
83634-1484
US

V. Phone/Fax

Practice location:
  • Phone: 208-813-4431
  • Fax: 208-922-3778
Mailing address:
  • Phone: 208-813-4431
  • Fax: 208-922-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-8096
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: