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General NPI Number Information
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NPI Number | 1528690179
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Entity Type | Individual
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Provider Name | JEREMIAH OSBORN LSW
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Gender | Male
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Dates
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Enumeration Date | 02/11/2020
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 921 S ORCHARD ST STE 101
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City | BOISE
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State | ID
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Zip | 83705-1916
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Country | US
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Telephone | 208-629-2436
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Fax | 208-712-6778
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Provider Business Mailing Address
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Address Line | 921 S ORCHARD ST STE 101
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City | BOISE
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State | ID
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Zip | 83705-1916
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Country | US
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Telephone | 208-420-3018
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Fax | 208-712-6778
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LSW-38962
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License Number State | ID
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