=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255790069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOLLIFF COUNSELING & BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2016
-----------------------------------------------------
Last Update Date | 02/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 837 POLE LINE RD STE 1050
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-3095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-736-0995
-----------------------------------------------------
Fax | 208-736-0999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 837 POLE LINE RD STE 1050
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-3095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-736-0995
-----------------------------------------------------
Fax | 208-736-0999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN ASSISTANT
-----------------------------------------------------
Name | CRYSTAL BRASSFIELD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-736-0995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------