Provider Demographics
NPI:1316654908
Name:HAMPSON, JENELLE MARIE
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:MARIE
Last Name:HAMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4236
Mailing Address - Country:US
Mailing Address - Phone:949-373-6676
Mailing Address - Fax:
Practice Address - Street 1:1014 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4236
Practice Address - Country:US
Practice Address - Phone:949-373-6676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-9143101YP2500X
IDLPC-9295101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional