Healthcare Provider Details

I. General information

NPI: 1578965422
Provider Name (Legal Business Name): JORGE DOMINGO REYES MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 E. FRANKLIN RD. SUITE 220-I
NAMPA ID
83687
US

IV. Provider business mailing address

995 N. WORLD CUP LN
EAGLE ID
83616
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-9497
  • Fax:
Mailing address:
  • Phone: 208-514-9497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-5723
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-5723
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: