Provider Demographics
NPI:1962111336
Name:WILSON, JENNIFER RAE (LSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 W 100 N
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5517
Mailing Address - Country:US
Mailing Address - Phone:208-852-6688
Mailing Address - Fax:
Practice Address - Street 1:1810 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5072
Practice Address - Country:US
Practice Address - Phone:208-552-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-42274104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker