Healthcare Provider Details

I. General information

NPI: 1912724998
Provider Name (Legal Business Name): REENDEAVOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 17TH AVE S STE 15
NAMPA ID
83651-4780
US

IV. Provider business mailing address

824 17TH AVE S STE 15
NAMPA ID
83651-4780
US

V. Phone/Fax

Practice location:
  • Phone: 208-992-3310
  • Fax: 208-228-9929
Mailing address:
  • Phone: 208-992-3310
  • Fax: 208-228-9929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER HAAGENSON
Title or Position: MANAGER, COUNSELOR
Credential: LPC 8975
Phone: 208-992-3310