Healthcare Provider Details

I. General information

NPI: 1235883190
Provider Name (Legal Business Name): JESSE ALLEN CASE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 E CLARK ST STE 330
POCATELLO ID
83201-3357
US

IV. Provider business mailing address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax:
Mailing address:
  • Phone: 208-542-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-41772
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: