Provider Demographics
NPI:1306682901
Name:LAYTON, JENNIFER PETTY (LSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PETTY
Last Name:LAYTON
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 1:9508 W CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7210
Mailing Address - Country:US
Mailing Address - Phone:208-244-2765
Mailing Address - Fax:
Practice Address - Street 1:4650 HAWTHORNE RD STE 3B
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-244-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-24471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker