Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | LPC-6675 | ID |
NPI | 1003436148 |
---|---|
Provider Name | Desiree Jenks-Asay |
First Address | Idaho Falls, ID 83404-5568 |
Second Address | Idaho Falls, ID 83401-6106 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2020 |
Last Update Date | 18/04/2020 |