Basic Information
| Provider Information | |||||||||
| NPI: | 1508216896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUNCAN | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2025 W PARK PL STE B | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086205250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | LMSW-35868 | ID | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 943036820 | 05 | ID | MEDICAID |