MEDICARE: JESSICA IVANCIC MS, LCPC

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	101YP2500X	Professional Counselor	LCPC7364	ID

General Provider Information

NPI Number	:	1922561612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA IVANCIC MS, LCPC

Provider Business Mailing Address
First Line	:	3320 N MILWAUKEE ST STE 160
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-0726
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 N MILWAUKEE ST STE 160
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-0726
Country	:	US
Telephone Number	:	208-817-0965
Fax Number	:

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

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	02/16/2024

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