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General NPI Number Information
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NPI Number | 1699413757
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Entity Type | Organization
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Legal Business Name | WILD LIFE COMMUNITY COUNSELING PLLC
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 01/11/2023
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Provider Practice Location Address
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Address Line | 264 BLACK MOUNTAIN RD
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City | BONNERS FERRY
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State | ID
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Zip | 83805-5308
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Country | US
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Telephone | 208-416-3850
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 172
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City | BONNERS FERRY
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State | ID
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Zip | 83805-0172
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Country | US
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Telephone | 208-416-3850
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Fax |
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Authorized Official
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Title or Position | LCSW
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Name | DEAN MICHAEL JENNINGS
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Credential | LCSW
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Telephone | 208-416-3850
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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