Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | LMSW38297 | ID |
NPI | 1003370958 |
---|---|
Provider Name | Jenny Shea |
First Address | Boise, ID 83704-5966 |
Second Address | Boise, ID 83704-5966 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2019 |
Last Update Date | 24/01/2019 |