=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972685915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK R JONES DBA CLEARWATER COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 MAIN ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-743-8101
-----------------------------------------------------
Fax | 208-746-7402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 MAIN
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83504-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-743-8101
-----------------------------------------------------
Fax | 208-746-7402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK R JONES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 208-943-8101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------