Provider Demographics
NPI:1528126158
Name:STEPHENSON, JOHN D (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:STEPHENSON
Suffix:
Gender:M
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:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0903
Mailing Address - Country:US
Mailing Address - Phone:208-782-0675
Mailing Address - Fax:208-782-0678
Practice Address - Street 1:1309 CAMAS ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3060
Practice Address - Country:US
Practice Address - Phone:208-782-0675
Practice Address - Fax:208-782-0678
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-26187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806939500Medicaid
ID807352800Medicaid