Provider Demographics
NPI:1083001630
Name:COBB, JESSE RAY (LCSW)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:RAY
Last Name:COBB
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2202
Mailing Address - Country:US
Mailing Address - Phone:208-452-8600
Mailing Address - Fax:
Practice Address - Street 1:1210 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2202
Practice Address - Country:US
Practice Address - Phone:208-452-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-309211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical