Provider Demographics
NPI:1124441951
Name:WILKS, JODI (LCSW)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WILKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 W PINE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8389
Mailing Address - Country:US
Mailing Address - Phone:208-841-8011
Mailing Address - Fax:
Practice Address - Street 1:8100 W EMERALD ST STE 150
Practice Address - Street 2:AFFINITY INC
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9057
Practice Address - Country:US
Practice Address - Phone:208-375-0752
Practice Address - Fax:208-345-5534
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-29875101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1369063Medicare PIN