Healthcare Provider Details

I. General information

NPI: 1013223445
Provider Name (Legal Business Name): NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 S EAGLE RD
MERIDIAN ID
83642-6707
US

IV. Provider business mailing address

2076 S EAGLE RD
MERIDIAN ID
83642-6707
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-7333
  • Fax:
Mailing address:
  • Phone: 208-955-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-202425
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-202505
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-29787
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-30636
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-1687
License Number StateID
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-28431
License Number StateID

VIII. Authorized Official

Name: MS. JENNIFER A LA JEUNESSE
Title or Position: CO-OWNER
Credential: LCSW, CMPE
Phone: 208-283-9121