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General NPI Number Information
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NPI Number | 1629841952
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Entity Type | Individual
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Provider Name | JONATHAN THACKER
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Gender | Male
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Dates
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Enumeration Date | 10/30/2023
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Last Update Date | 10/30/2023
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Provider Practice Location Address
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Address Line | 75 S 1ST W
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City | PRESTON
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State | ID
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Zip | 83263-1204
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Country | US
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Telephone | 208-852-2370
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Fax |
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Provider Business Mailing Address
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Address Line | 1327 N 25 E
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City | LAYTON
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State | UT
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Zip | 84041-2977
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Country | US
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Telephone | 435-512-6453
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LMSW-44232
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License Number State | ID
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