Healthcare Provider Details

I. General information

NPI: 1376400978
Provider Name (Legal Business Name): JEREMIAH WOODRUFF LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 N 3988 E
RIGBY ID
83442-5310
US

IV. Provider business mailing address

153 N 3988 E
RIGBY ID
83442-5310
US

V. Phone/Fax

Practice location:
  • Phone: 480-603-8905
  • Fax:
Mailing address:
  • Phone: 480-603-8905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2271392
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: