Healthcare Provider Details

I. General information

NPI: 1306411376
Provider Name (Legal Business Name): DEFUNKIFY COUNSELING & CONSULTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 05/23/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3484 N BRYCE CANYON PL
MERIDIAN ID
83646-6061
US

IV. Provider business mailing address

3484 N BRYCE CANYON PL
MERIDIAN ID
83646-6061
US

V. Phone/Fax

Practice location:
  • Phone: 208-971-1054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TONCH JAKOVAC
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential:
Phone: 208-971-1053