=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093844474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY W. WEBB, PH.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2007
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2304 N. COLE RD. SUITE B
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-376-0453
-----------------------------------------------------
Fax | 208-376-0477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2304 N. COLE RD SUITE B
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-376-0453
-----------------------------------------------------
Fax | 208-376-0477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAY W. WEBB
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 208-376-0453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY-360
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------