Basic Information
| Provider Information | |||||||||
| NPI: | 1952319394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMPION | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | P.H.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2365 E GALA ST | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836424881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082881920 | ||||||||
| FaxNumber: | 2082882844 | ||||||||
| Practice Location | |||||||||
| Address1: | 2365 E GALA ST | ||||||||
| Address2: | SUITE #2 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836424881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082881920 | ||||||||
| FaxNumber: | 2082882844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY-373 | ID | X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PSY 373 | ID | X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.