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General NPI Number Information
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NPI Number | 1982338885
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Entity Type | Individual
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Provider Name | JACQUELYNNE ROSE CARLSON
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Gender | Female
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Dates
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Enumeration Date | 07/15/2022
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Last Update Date | 03/06/2025
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Provider Practice Location Address
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Address Line | 1812 N LAKEWOOD DR STE 100
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2635
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Country | US
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Telephone | 208-966-4476
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Fax | 208-966-4475
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Provider Business Mailing Address
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Address Line | 850 W IRONWOOD DR STE 202
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City | COEUR D ALENE
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State | ID
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Zip | 83814-4903
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Country | US
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Telephone | 208-664-2175
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Fax | 208-664-1226
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 121595
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License Number State | TX
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