Healthcare Provider Details

I. General information

NPI: 1841374360
Provider Name (Legal Business Name): JEREMY TODD EHMKE ED.S., NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17659 MONARCH WAY
NAMPA ID
83687-9076
US

IV. Provider business mailing address

17659 MONARCH WAY
NAMPA ID
83687-9076
US

V. Phone/Fax

Practice location:
  • Phone: 208-866-5200
  • Fax:
Mailing address:
  • Phone: 208-866-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3671793
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: