Healthcare Provider Details

I. General information

NPI: 1245353440
Provider Name (Legal Business Name): JOHN L CHRISTENSEN PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE SUITE 302
POCATELLO ID
83201
US

IV. Provider business mailing address

13235 N MANNING LN
POCATELLO ID
83202-5184
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-0150
  • Fax: 208-233-0159
Mailing address:
  • Phone: 208-233-0150
  • Fax: 208-233-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License NumberPSY202148
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPSY202148
License Number StateID

VIII. Authorized Official

Name: NICHOLE CHRISTENSEN
Title or Position: SECRETARY
Credential:
Phone: 208-234-1707