Provider Demographics
NPI:1962159731
Name:JORDAN, KASSIDI RENEE (LMSW)
Entity type:Individual
Prefix:
First Name:KASSIDI
Middle Name:RENEE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 W BANK DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2565
Mailing Address - Country:US
Mailing Address - Phone:208-342-3612
Mailing Address - Fax:
Practice Address - Street 1:2424 W BANK DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2565
Practice Address - Country:US
Practice Address - Phone:208-342-3612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39590104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker