Provider Demographics
NPI:1902321888
Name:DERR, JAYNE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JAYNE
Middle Name:
Last Name:DERR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JAYNE
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3340 E. GOLDSTONE WAY
Mailing Address - Street 2:ATT: SANDRA RODRIGUEZ
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:131 N ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9204
Practice Address - Country:US
Practice Address - Phone:208-302-0900
Practice Address - Fax:208-302-0955
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID310921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical