Healthcare Provider Details

I. General information

NPI: 1982568473
Provider Name (Legal Business Name): JACLYN PARKHOUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 STANFORD AVE
POCATELLO ID
83201-3424
US

IV. Provider business mailing address

72 STANFORD AVE
POCATELLO ID
83201-3424
US

V. Phone/Fax

Practice location:
  • Phone: 208-909-9510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: