Healthcare Provider Details

I. General information

NPI: 1669385464
Provider Name (Legal Business Name): MR. JONATHAN ARTHUR AUSTAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 E 4TH N STE 235
REXBURG ID
83440-6009
US

IV. Provider business mailing address

343 E 4TH N STE 235
REXBURG ID
83440-6009
US

V. Phone/Fax

Practice location:
  • Phone: 208-243-9526
  • Fax: 208-366-1969
Mailing address:
  • Phone: 208-243-9526
  • Fax: 208-366-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1381831
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: