Basic Information
| Provider Information | |||||||||
| NPI: | 1669844320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAZZLE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITHEE | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | CHERI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6126 W STATE ST # 409 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837032741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 6126 W STATE ST # 409 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837032741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083767083 | ||||||||
| FaxNumber: | 2083215069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2015 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC5973 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | LPC5973 | 01 | ID | STATE LICENSE | OTHER |