Healthcare Provider Details

I. General information

NPI: 1164723334
Provider Name (Legal Business Name): JJST ENTERPRISES CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 E 4TH N SUITE 244
REXBURG ID
83440-6002
US

IV. Provider business mailing address

343 E 4TH N SUITE 244
REXBURG ID
83440-6002
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-0088
  • Fax:
Mailing address:
  • Phone: 208-356-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-2823
License Number StateID

VIII. Authorized Official

Name: MR. SCOTT KAY ANDERSEN
Title or Position: OWNER
Credential: LCPC
Phone: 208-356-0088