Healthcare Provider Details

I. General information

NPI: 1609566009
Provider Name (Legal Business Name): JONATHAN HOLM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E CALDERWOOD DR # 102
MERIDIAN ID
83642-7482
US

IV. Provider business mailing address

3518 W MORERE DR
MERIDIAN ID
83642-1147
US

V. Phone/Fax

Practice location:
  • Phone: 208-841-6378
  • Fax:
Mailing address:
  • Phone: 208-841-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4761571
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number059532
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: