Provider Demographics
NPI:1992135818
Name:COFFEY-KELLY, JAMIE TISA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:TISA
Last Name:COFFEY-KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:ID
Mailing Address - Zip Code:83611-1330
Mailing Address - Country:US
Mailing Address - Phone:208-382-4285
Mailing Address - Fax:208-382-5081
Practice Address - Street 1:402 LAKE CASCADE PKWY
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:ID
Practice Address - Zip Code:83611-7702
Practice Address - Country:US
Practice Address - Phone:208-382-4285
Practice Address - Fax:208-382-5081
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-376391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1285767574Medicaid