Healthcare Provider Details

I. General information

NPI: 1801969548
Provider Name (Legal Business Name): JACQUELINE GEDEIK LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 E POLSTON AVE SUITE 4 JOURNEY TO WELLNESS COUNSELING
POST FALLS ID
83854-6409
US

IV. Provider business mailing address

4549 E HAYDEN LAKE RD
HAYDEN ID
83835-8560
US

V. Phone/Fax

Practice location:
  • Phone: 208-699-6756
  • Fax: 208-457-1202
Mailing address:
  • Phone: 208-714-4256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-2829
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: