=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750507604
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSIE A BACON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MISSION ROAD BLDING 248 FORT HALL INDIAN AGENCY
-----------------------------------------------------
City | FORT HALL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-237-5631
-----------------------------------------------------
Fax | 208-237-5796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1068 E RESERVATION RICH LN
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-7052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-681-6980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-32218
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------