Provider Demographics
NPI:1194996868
Name:LUSK, JESSICA (LSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LUSK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-233-3353
Mailing Address - Fax:
Practice Address - Street 1:1151 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-233-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-26003104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker