=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134994858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MARIE MAYBERRY L.M.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2023
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2025 W PARK PL STE 105
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-2787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-274-3267
-----------------------------------------------------
Fax | 208-719-7952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1103
-----------------------------------------------------
City | RATHDRUM
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-659-2049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------