=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174656664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J&M MENTAL HEALTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 N BROADWAY ST
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-2706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1472
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR
-----------------------------------------------------
Name | BERNICE KAYE MARLEY
-----------------------------------------------------
Credential | LSW
-----------------------------------------------------
Telephone | 208-782-1102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------