Provider Demographics
NPI:1720620750
Name:SMIDT, JIM
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:SMIDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5123
Mailing Address - Country:US
Mailing Address - Phone:208-755-0660
Mailing Address - Fax:208-777-7691
Practice Address - Street 1:820 N WILLIAM ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5123
Practice Address - Country:US
Practice Address - Phone:208-755-0660
Practice Address - Fax:208-777-7691
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46949261QM0855X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health