MEDICARE: MS. JACKELLE N KNICKREHM LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LMSW-35335	ID

General Provider Information

NPI Number	:	1740962315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACKELLE N KNICKREHM LMSW

Provider Business Mailing Address
First Line	:	13477 W BLUEBONNET DR
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-1341
Country	:	US
Telephone Number	:	208-254-1112
Fax Number	:	208-939-9110

Provider Business Practice Location Address
First Line	:	13477 W BLUEBONNET DR
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-1341
Country	:	US
Telephone Number	:	208-254-1112
Fax Number	:	208-939-9110

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2023
Last Update Date	:	02/13/2026

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