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General NPI Number Information
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NPI Number | 1649694233
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Entity Type | Individual
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Provider Name | ELIZABETH A JACKSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 02/18/2014
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Last Update Date | 03/03/2024
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Provider Practice Location Address
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Address Line | 1111 S ORCHARD ST STE 100
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City | BOISE
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State | ID
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Zip | 83705-1961
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Country | US
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Telephone | 208-794-9588
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Fax |
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Provider Business Mailing Address
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Address Line | 1111 S ORCHARD ST STE 100
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City | BOISE
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State | ID
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Zip | 83705-1961
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Country | US
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Telephone | 208-794-9588
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PCSW-535
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LMSW-31478
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-33837
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License Number State | ID
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