Healthcare Provider Details

I. General information

NPI: 1255871455
Provider Name (Legal Business Name): JENNA C BREHM-GIBSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 CARRIAGE LN N
TWIN FALLS ID
83301-7589
US

IV. Provider business mailing address

3301 43RD AVE S
FARGO ND
58104-6638
US

V. Phone/Fax

Practice location:
  • Phone: 541-778-5656
  • Fax:
Mailing address:
  • Phone: 541-778-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5358
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5358
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: