Healthcare Provider Details

I. General information

NPI: 1114321163
Provider Name (Legal Business Name): MERIDIAN NEUROPSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 S MERIDIAN RD STE 100
MERIDIAN ID
83642-7962
US

IV. Provider business mailing address

3597 E MONARCH SKY LN STE 240
MERIDIAN ID
83646-1055
US

V. Phone/Fax

Practice location:
  • Phone: 208-895-9852
  • Fax: 208-629-1231
Mailing address:
  • Phone: 208-391-7274
  • Fax: 208-629-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-202728
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY-202728
License Number StateID

VIII. Authorized Official

Name: DR. JASON SOUTHWICK
Title or Position: MANAGER
Credential: PHD
Phone: 208-895-9852