Healthcare Provider Details

I. General information

NPI: 1851217426
Provider Name (Legal Business Name): JACOB BALLARD LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24799 LANSING LN
MIDDLETON ID
83644-5341
US

IV. Provider business mailing address

4412 S CHINOOK AVE
BOISE ID
83709-5500
US

V. Phone/Fax

Practice location:
  • Phone: 208-742-4229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4981810
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: