Healthcare Provider Details

I. General information

NPI: 1902396153
Provider Name (Legal Business Name): DAVINA GJENNESTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 MAIN AVE S
TWIN FALLS ID
83301-6232
US

IV. Provider business mailing address

357 BLUE LAKES BLVD N APT 1
TWIN FALLS ID
83301-4876
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-0407
  • Fax:
Mailing address:
  • Phone: 334-750-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-6907
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: