Healthcare Provider Details

I. General information

NPI: 1093087033
Provider Name (Legal Business Name): JEFFERSON H KRACZEK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 BEVERLAND ROAD
MACKAY ID
83251-8048
US

IV. Provider business mailing address

PO BOX 402
MACKAY ID
83251-0402
US

V. Phone/Fax

Practice location:
  • Phone: 208-588-2770
  • Fax: 208-588-2984
Mailing address:
  • Phone: 208-588-2770
  • Fax: 208-588-2984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW27821
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: