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General NPI Number Information
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NPI Number | 1770237034
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Entity Type | Individual
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Provider Name | MARK STEVEN DE JONG LMSW
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Gender | Male
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Dates
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Enumeration Date | 02/07/2022
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Last Update Date | 02/07/2022
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Provider Practice Location Address
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Address Line | 2424 W BANK DR
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City | BOISE
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State | ID
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Zip | 83705-2565
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Country | US
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Telephone | 208-342-3612
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Fax |
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Provider Business Mailing Address
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Address Line | 5404 ORMSBY AVE
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City | CALDWELL
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State | ID
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Zip | 83607-1905
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Country | US
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Telephone |
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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-37345
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License Number State | ID
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