Provider Demographics
NPI:1427676063
Name:GOODALL, JENNIFER JANELLE (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANELLE
Last Name:GOODALL
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 1:2632 N LARCHMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6093
Mailing Address - Country:US
Mailing Address - Phone:661-317-5546
Mailing Address - Fax:
Practice Address - Street 1:1276 W RIVER ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7083
Practice Address - Country:US
Practice Address - Phone:661-317-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39807104100000X
ID450311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker