=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114048881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF JEROME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 08/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 882 VALLEY RD
-----------------------------------------------------
City | HAZELTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83335-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-829-5353
-----------------------------------------------------
Fax | 208-829-5548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 882 VALLEY RD
-----------------------------------------------------
City | HAZELTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83335-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-829-5353
-----------------------------------------------------
Fax | 208-829-5548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAID COORDINATOR
-----------------------------------------------------
Name | MRS. CHRISTINA K ALEXANDER
-----------------------------------------------------
Credential | M.S.,CCC-SLP
-----------------------------------------------------
Telephone | 208-829-5333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------