Provider Demographics
NPI:1124160627
Name:CROUDER, JENNIFER M (LCPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:CROUDER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 ROBERT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3161
Mailing Address - Country:US
Mailing Address - Phone:208-440-8882
Mailing Address - Fax:
Practice Address - Street 1:750 WARM SPRINGS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6475
Practice Address - Country:US
Practice Address - Phone:208-344-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3098101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional