Basic Information
| Provider Information | |||||||||
| NPI: | 1487880001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLURE | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 42ND ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503122701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152558399 | ||||||||
| FaxNumber: | 5152558405 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 42ND ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503122701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152558399 | ||||||||
| FaxNumber: | 5152558405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 007728 | IA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 00124 | IA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0469676 | 05 | IA | MEDICAID |