Provider Demographics
NPI:1790652709
Name:JEROME, DESIREE (LMT)
Entity type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:JEROME
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6857
Mailing Address - Country:US
Mailing Address - Phone:208-365-8154
Mailing Address - Fax:
Practice Address - Street 1:1319 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6857
Practice Address - Country:US
Practice Address - Phone:208-365-8154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-237225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty