Healthcare Provider Details

I. General information

NPI: 1184517583
Provider Name (Legal Business Name): JANELLE JAZZ GELVEZON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W USTICK RD STE 100
MERIDIAN ID
83646-7733
US

IV. Provider business mailing address

4613 W KOOTENAI PL
BOISE ID
83705-2041
US

V. Phone/Fax

Practice location:
  • Phone: 208-576-6664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4171869
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: