Provider Demographics
NPI:1215639182
Name:MENTAL HEALTH JIU JITSU PLLC
Entity type:Organization
Organization Name:MENTAL HEALTH JIU JITSU PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:SANDRO
Authorized Official - Last Name:RUMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:208-627-9930
Mailing Address - Street 1:105 PINE ST STE 105A
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1369
Mailing Address - Country:US
Mailing Address - Phone:208-627-9930
Mailing Address - Fax:
Practice Address - Street 1:105 PINE ST STE 105A
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1369
Practice Address - Country:US
Practice Address - Phone:208-627-9930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)