Basic Information
| Provider Information | |||||||||
| NPI: | 1982230710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUNCELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | WYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE DR. | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083021200 | ||||||||
| FaxNumber: | 2083021255 | ||||||||
| Practice Location | |||||||||
| Address1: | 1072 N LIBERTY ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083021200 | ||||||||
| FaxNumber: | 2083021255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2020 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 59664 | ID | Y | Other Service Providers | Midwife |
No ID Information.