Healthcare Provider Details

I. General information

NPI: 1114297744
Provider Name (Legal Business Name): ANNA RENE JUNGERT LCSW,CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNA RENE MATNEY LCSW, CADC

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S MAIN STREET
RIGGINS ID
83549
US

IV. Provider business mailing address

PO BOX 433 306 MAIN STREET #3
RIGGINS ID
83549-1483
US

V. Phone/Fax

Practice location:
  • Phone: 208-816-6958
  • Fax:
Mailing address:
  • Phone: 208-816-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCSW-29069
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2012-267
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCSW-29069
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-29069
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: