=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215610357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILINDA ROSE WRAY LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 671 N 3RD W
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-270-1565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 671 N 3RD W
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-270-1565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LMSW-42178
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------